Stroke Recovery Canada - Memeber Form

*Member Services* Join Stroke Recovery Canada™ and receive a free subscription to our newsletter with up-to-date information on stroke recovery and rehabilitation. Membership is free! Stroke Recovery Canada Form Yes, I would like to become a member of Stroke Recovery Canada™.
Please complete the following information. I am a:
family/friend of a stroke survivor
health care professional
stroke survivor
other:
For stroke survivors:
Year of your stroke:
Year of birth:
Please let us know how you heard about us:
community organization
family/friend
health care professional
hospital staff
media/Internet

First Name:
Last Name:

Address:

City:

Postal Code:

Province:

Home Phone No.

Office Phone No.

Email Address:

( including your e-mail address helps us save postage and mailing costs, providing us with more resources for this program.)
*We comply with Canada’s Personal Information Protection and Electronic Documents Act