North Lambton Community Health Centre

With Divisions In

w West Lambton w Kettle Point w East Lambton

Membership Form

Family Name: _______________________________________________________________

Family Members: ________________________ _______________________________

_______________________________________ _______________________________

_______________________________________ _______________________________

911 and Mailing Address: _____________________________________________________

Phone Number: _______________________________________________________(Home)

_______________________________________________________(Work)

Email Address: _____________________________________________________________

Membership Fees:

Individual $5.00 / year $50.00/Lifetime

Family $10.00/year $100.00/Lifetime

Amount Paid: ______________________________________________________________

The membership is due before the start of the Annual General Meeting.

Would you like a separate newsletter e-mailed to your home? r Yes rNo

Would you like to tour or learn more about the Community Health Centre? r Yes r No