Form

Please print and mail to address below.

Membership Fee:
Individual / Family* $35
Camp/Daycare/School $50
Health Professionals $50
Corporate $100
 
*Anaphylaxis affects the whole family and it requires the support of all family members
   
Donation:
   
Products:
   
TOTAL
   
Surname:
First Name:
Please list names of family members:
Address:
City:
Prov:
Postal Code:
Tel:
Fax:
E-mail:
   
Mail cheque for payable to the Anaphylaxis Network of Canada
Visa #
  Expiry Date
Signature X
   

Mail completed membership form to:

Anaphylaxis Network of Canada
P.O. Box 57524, 1500 Royal York Road
Toronto, Ontario, Canada M9P 3B6

   
   
and enclose payment The Registry product sales form
       
The Anaphylaxis Network of Canada is a non-profit charitable organization operated by volunteers. We depend on your generous donations. Receipts will be issued by donations of $10 or more. Charitable registration #88720 8676 RR001.