Membership Form

Yes, I wish to be counted as a registered member of the Vancouver Island Head Injury Society (VIHIS). I understand that the provision of services DOES NOT depend on paid membership.

Mr.     Ms.     Dr.     name:

Address:

City:             Province:             Postal code:

Telephone:                                     Email:

Membership Dues Enclosed (suggested donations)

Individual $10

Friend $20

Family $25

Professional $100

Corporate $400 +

 

Date:                                                                        Signature

 

Please Make Cheques or Money Order payable to: Vancouver Island Head Injury Society.

VIHIS Address: 100-651 Queens Avenue

Victoria, BC V8T 1L9