Last Name:

First Name:

Dr.      Ms.      Mr.      Miss      Mrs.      Other _______

Address:

City:

Province:

Postal Code:

Telephone:

E-mail

Physician Membership $100

Non-Physician Membership $50

Supporters (Honorary mention and a free copy of The Canadian Guide to Health and the Environment) $200

Students, retirees, those with limited income $25

Member Organizations (one vote per organization) $50
(My cheque is made out to the Canadian Association of Physicians for the Environment)

I would like updates on CAPE-related activities. Please put me on the CAPENEWS listserve (for members only).

I want to get involved in CAPE.

I am sending a donation of:

$50   $100   $500   $1000   Other________    to support CAPE’s environmental advocacy work (My cheque is made out to the Canadian Association of Physicians for the Environment).

Please take a monthly donation of $ from my account on the 1st of each month. (I have attached a voided cheque and signed below)

Signature______________________________

I would like a charitable tax receipt for my donation. I understand that these donations will only be used for research and education activities. (My cheque is made out the Canadian Health and Environment Education and Research Foundation (CHEER))

Check here if you do not want your name shared with other like-minded organizations.