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 January.
- Payment can be submitted online with Debit, Credit or PayPal at the end of this form.
- Please contact us at childrensheartsociety@gmail.com with any questions or concerns regarding this fee.
Information Acknowledgement*

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

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

Heart FamilyProfessionalSupporter
Full Name*

First NameLast Name
Email*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Heart Child Information (If Applicable)
Heart Child Name

First NameLast Name
Date of Birth

MonthDayYear
Gender

MaleFemale
Heart Defect/Disease
Surgeries (if any)
Sibling Information

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

MonthDayYear
Sibling Name
Date of Birth

MonthDayYear
Sibling Name
Date of Birth

MonthDayYear

Heart Child Information (If Applicable)