NAME: _______________________________________________________________

                                    Please Print (Surname) (Middle Int.) (First)

ADDRESS:_____________________________________________________________

CITY/TOWN____________________ PROV_________________P. CODE._________

Birthdate: ___________________ Telephone Number __________________________

Email Address______________________________

 

Is this a new membership or a renewal?                  

I would like to become a new member     ___   I would like to renew my membership___

Membership Fees:      $25.00___  Enclosed  

                               $12.50___  Enclosed for membership Dec. 2006 to€“ July 2007

 

Do you wish to receive our TNAC Newsletter by Email? ___ Mail?___

 

Do you wish to receive newsletters from TNA (USA) ___ Yes         ___No (please select no if you already                                                                                                                 receive these mailings directly from TNA)

            If yes, do you wish to receive TNA information by Email? ___ Mail? ___

 

Are you interested in starting up a Support Group in your area?   Yes  ___ No ___

            If yes, would you like information on how to start a support group? ___  Yes         ___  No

 

Are you interested in being a Telephone Contact Person? ___  Yes  ___  No

A

re you interested in attending a Support Group? ___  Yes   ___No

            If yes, can we give your contact information to a support group leader in your area? ___ Yes___ No

TNAC exists largely on the support of donations.  If you would like to make a donation for yourself or in memory of a loved one please indicate below.

I would like to make a donation to TNAC in the amount of:  $________ (all donations are tax deductible)

I would like to make a donation in memory of:  (please list name of person):______________________

I would like TNAC to acknowledge the donation by sending a note to: (please write name and mailing contact information of family below)

 

Note:  Would you like your name and/or contact information listed in our membership directory?  This will be accessible by members only.  With your permission we would also list your contact information to others with TN and/or to local support groups in your community.  If you would like your name listed for any of the above please sign and date below checking off the boxes for the areas where we may release this information.  Note that TNAC does not sell or give out its membership list to any organization. 

 

_________________________________________________________

Name, signature, and date

 

I, the above signed, give permission for TNAC to list my name and contact information as indicated below left for the purposes indicated below right:

___name                                                                      ___telephone support (for others to call me)

___phone                                                                     ___membership list

___email                                                                      ___support group

___street address                                                                   

 

Check enclosed in the amount of:

$__________  membership fee

$ __________ donation

$ __________ TOTAL

Please make checks payable to TNAC and return to:

Trigeminal Neuralgia Association of Canada Membership