To become a member of the SSAH Provincial
Coalition, please print this form and fill it out.
Make cheque payable to BDACI and send your fee along with this form to :
SSAH Provincial Coalition
c/o 2495 Parkedale Ave., Unit # 4
Brockville, ON K6V 3H2
Please print this Membership form and send to the address above with
your fee.
Name:
_________________________________________________________
Address:
_______________________________________________________
City & Postal Code:
_______________________________________________
Phone number: ___________________________________________________
Email Address: ___________________________________________________
Region Office:
___________________________________________________
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Family Member Fee or Individual Fee - $ 5.00
Organization or Agency Fee $ 250.00 - $500.00
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Copyright SSAH Provincial Coalition