Membership Application

Count me in!  I would like to join 
Citizens With Disabilities – Ontario


?	New 			?	Renewal

Your Name: 

Address:  

Apartment # 

Email

City:	

Province: Ontario	

Postal Code: 

Home Telephone: 

Other Phone Number: 

The following information is for our records only.  

In what form would you prefer to receive CWDO information or updates? 
E-mail, Large Print, Telephone, at the www.cwdo.org website or 	Other

Your answer:

What are your interests? 
Aging with a disability, Arts and Culture, Assistive devices, Attendant services, Accessibility, Education, Employment, Housing, Mental Health, ODSP/Income Security, Recreation, Transportation 	or Other 
 
Your answer:

Are you a person with a disability?  Please answer yes or no:  
Are you close to someone who has a disability? Please answer yes or no:  

If yes to either question, what is the general category(ies) of disability you experience?  
ADD/ADHD, Agility, Brain Injury, Chronic Pain, Hearing, Intellectual Disability, Learning Disability, Mental Health, Mobility, Speech, Stamina, Vision, or Other

Your answer:

Are you applying for membership with CWDO as an association, club, organization or disability related business interested in furthering the full participation of all persons in the social, economic and political life of their communities? Please answer yes or no:  

What would you like to accomplish as a member of CWDO?

Is there anything else you would like to tell us about yourself?

How did you learn about Citizens With Disabilities – Ontario?
TV, radio, newspaper, word of mouth, chat room, internet, from a friend,   other

Your answer:

Please note that processing your membership application by our volunteers can take up to 6 weeks.  If you feel it is taking too long before you hear from anyone, please feel welcome to send the Membership Committee Chair an e-mail to CWDO Membership Committee at membership@cwdo.org and put MEMBERSHIP in the subject line.
 
Date:
Signature of Applicant:
Applications sent by email will be deemed to have been signed.

Alternate formats are available on request.  
If you need assistance to complete this form, email us at membership@cwdo.org or call our voice line at Membership Voice Line: 807-473-0909                 

Please send your completed form to:

Chair
CWDO Membership Committee
1201 Jasper Drive
Box 103
Thunder Bay, ON  P7B 6R2

Or Email to:  membership@cwdo.org 
Together we are stronger!