Membership Form and Renewal

Membership Form and Renewal
Membership Information

The Children’s Heart Society is a volunteer run, non-profit organized society supporting families of children with acquired and congenital heart disease.

Annual Membership Fee
- Annual membership fee is $30.00 per family, renewed each July.
- Payment can be submitted online with Debit, Credit or PayPal at the end of this form.
- Please contact us at childrensheart@shaw.ca with any questions or concerns regarding this fee.
Information Acknowledgement *

I have read and understand the membership information as described above.
Registration Type *

New Member Existing Member (Renewal)
I represent a... *

Heart Family Professional Supporter
Full Name *

First Name Last Name
Email *
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Heart Child Information (If Applicable)
Heart Child Name

First Name Last Name
Date of Birth

Month Day Year
Gender

Male Female
Heart Defect/Disease
Surgeries (if any)
Sibling Information

(Include up to three siblings if applicable.)
Sibling Name
Date of Birth

Month Day Year
Sibling Name
Date of Birth

Month Day Year
Sibling Name
Date of Birth

Month Day Year

Permissions and Policies

We collect only the personal information that we need for the purposes of providing services to our members, including personal information needed to: deliver or notify membership of products and services; enroll a member in a program; send out membership renewal notices. For further information, contact our office at (780) 454-7665 or childrensheart@shaw.ca
By Becoming a Member of the CHS I agree to the Following: *

The CHS may include my name, my child’s name and defects on the membership information list. The CHS may use my/my child’s photo or name in any of their displays, exhibits or publications. I consent to the collection of my/my child’s personal information. Receiving communications from the Children's Heart Society. I agree to volunteer a minimum of 3 hours with the Children's Heart Society.
Interested in Volunteering?

Yes! As a member I wish to help The Children’s Heart Society by volunteering. Please contact me about contributing my time to the CHS.
Membership Fee Payment
Select any that apply:

I have already paid the annual membership fee. I am unable to complete my payment with debit, credit or PayPal.
Complete payment by leaving this checked: *
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Annual Membership Fee (Per Family) $ 30.00 CAD
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Heart Child Information (If Applicable)