Epilepsy Association of Calgary

Membership/Donation Print-out Form

_______________ Anuual Membership $20.00 (January 1 - December 31) 

_______________ Life Membership $200.00

I would like my membership/donation to be directed to
____ the Calgary Office
____ the Central Alberta Office

We recognize our donors in our quarterly newsletter and our members and donors in our Annual Report. These documents are shared with members, funders, program participants, and others in the community who are interested in our work. If you do not wish to have your name published, please call us at 230-2764 or indicate your wishes in the box below:


[    ]        I do not wish to have my name published in the Annual Report or Epigram Newsletter.


__________________________ _________________________ __________
Name (Please Print)                         Signature                                           Date