SOUTH BURNABY NEIGHBOURHOOD HOUSE

MEMBERSHIP APPLICATION

Last Name:____________________________First Name:_________________________

Sex:_____ Spouse (first and last name)______________________________________

Child(ren) 1.____________________________________Age:_______ Sex ____

2.____________________________________ Age:_______ Sex ____

3.____________________________________ Age:_______ Sex ____

Address:__________________________________________

City:______________________ Postal Code:______________________

Phone:_____________________ Date:_____________

Program: Family Place SACC Maywood SACC Marlborough

Community Programs Name ____________________

Membership Fees:

Individual $2.00_____________ Family $5.00_____________

Yes!!!! I would like to make a donation. Please accept my contribution of $__________

Please mail or drop off this form to the Neighbourhood House at:

6768 Jubilee Ave. Burnaby, BC V5H 3G8

Thank you for supporting the South Burnaby Neighbourhood House!

OFFICE USE ONLY

Membership # Expiry Date

Type