Donation/Membership Registration

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All donations include a 1 year membership and subscription to our Newslinks newsletter. Your membership runs for one year from the issued date, which will appear on your membership card. All donations $25 or greater are eligible for a tax receipt.

Yes, I would like to help the CMA with a one-time donation of
or other $
 
Individual Donation
Corporate Donation
Memorial Donation - In memory of
Honorarium - In honour of
For memorial or honorarium donations please specify who the acknowledgement card should be sent to.
   
If you would like to designate your donation to a specific campaign, please select one (optional)
Annual Christmas Campaign
CMA Medical Conference
Other  
"Volunteerism - The Gift of Time"
I wish to share the gift of time ,please contact me
   
Name
Address
City
Province
Postal Code
 
I prefer to receive Newslinks by email, Email :
I prefer NOT to receive Newslinks by email
Yes, I want to receive the new "Medical Emergency Card" (one card per family free with initial donation/membership)
Yes, I want to receive additional "Medical Emergency Card" x $8.00 = $
I would like my donation to remain anonymous.
 
Title Mr. Mrs. Ms. Dr.
First Name*
Last Name*
Email*
Address*
City/Town*
Province*
Postal Code*
Sex Male Female
Date of Birth Day Month Year
Occupation
Work Phone
   
Please submit the information below if you or a family member have Marfan Syndrome, otherwise you may proceed to checkout below
Name of person with Marfan Syndrome (if different from above)
First Name
Last Name
Sex Male Female
Date of Birth Day Month Year
At what age were you diagnosed?
Which physician made the diagnosis?
Any other Marfan patients in your family?
Where did you hear about the Association?
0.00
   

 

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First Name
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Email