Membership Form - Individual Member

Membership Term

Memberships are valid as long as the member meets the current membership criteria.

Your Name*

E-mail Address*

Telephone

Your Region*

Sélectionner ou saisir une valeur

Réseau's Activities

Would you like to play a more active role in the Réseau's activities?*

Oui/Yes

Non/No

Pas pour l'instant/Not at the moment

Board of Directors

Consultations/Focus Groups

Committees and Working Groups

Other (specify) :

Personal Information

For statistical purposes only

Consent

To become an individual member of the Réseau, you must:

♦ Be at least 18 years old;

♦ Be Francophone or Francophile;

♦ Reside or work in Northern Ontario;

♦ Have at interest French language health services.

I have read and understood the eligibility criteria to become an individual member of the Réseau, and certify that my application is in compliance with these criteria.*

Electronic Signature*

If you wish to receive a copy of your form by e-mail, don't forget to check your junk mail.

Envoyez-moi une copie de mes réponses