Membership Form

Membership - $25.00

Membership includes the quarterly Share & Care, other mailings and lecture announcements, access to support groups and education programs and all other activities. Complimentary membership is available for people with limited incomes.

How to become a member:

Call (514) 486-1448
or
E-mail amique@amiquebec.org
or

Print and complete the form below and mail it to:
AMI Québec Action on Mental Illness Inc
5253 Décarie Blvd., Suite 200, Montreal, Quebec, H3W 3C3

Membership Application Form

First Name _____________________

and/or
Organization ___________________

Address _______________________

Province ______________________

Phone Number __________________

Last Name ____________________

City __________________________

Postal Code ___________________

Email Address __________________

Choices:
Please circle the appropriate answer and fill in the details where necessary..

I have a family member with a mental illness. [ yes | no ]
If yes, what is the diagnosis?

I have a mental illness. [ yes | no ]
What is the diagnosis?

I am a mental health professional. [ yes | no ]
Name of organization / hospital

How did you hear of AMI-Québec? Please specify:

Payment method: Cheque VISA MasterCard

Credit Card Number ___________________________________

Expiry Date: _____________

Name of cardholder: _______________________________

AMI-Québec Action on Mental Illness
5253 Decarie Blvd., Suite 200, Montreal, Quebec, H3W 3C3