Unit #5 – 165 Hollinger Crescent
Kitchener, Ontario N2K 2Z2
Membership Application Form
Yes, I would like to make a difference in the lives of people who are affected by epilepsy
and become a member of Epilepsy Waterloo-Wellington.
As a member I may or will have:
Access to Epilepsy Waterloo-Wellington’s resource library which contains
numerous books and videos on the subject of epilepsy.
Access to informational pamphlets and articles.
Access to our monthly awareness groups, support and referrals.
Receive reduced rates to conferences and speakers that are presented by
Voting privileges at Annual General Meeting. One Vote for Individual and only
one vote per family.
On recommendation of the EWW board, there will be no fees for individual, family or
fixed income members. All memberships are to be renewed annually, except for those
holding honorary memberships. Organization memberships will still be charged a $50
fee. Charitable donations are greatly appreciated and receipts will be issued for income
tax purposes (Membership fees are not considered a donation).
Name: ___________________________ Phone Number (Home): ______________
Address: _________________________ (Business): ________________________
City: _____________________________ (Cell): ____________________________
Postal Code: _______________________ Email: ___________________________
Please inform EWW should your contact information change as soon as possible.
Type of Membership:
______ ______ _______
Amount Enclosed: __________________
Charity # 889926820RR0001
Please make cheques payable to: Epilepsy Waterloo-Wellington