Type of membership:

General    Associate

Name:

Organization (if any):

E-mail:

Telephone:

Fax:

Mailing address:

City/town:

Postal Code:

For General members only:

Are you over 16 years of age?

Yes    No

Ancestry:

First Nations    Inuit    Métis
Other  

Status:

Status    Non-status

Are you:

Person with a disability
Guardian or parent of an aboriginal person with a disability
Person who works with disabled aboriginal people
      (please check all that apply)

Type of disability:

Comments: