CHHA
   
 

CHHA Online Membership Form

Please complete the following form and click "Submit" at the bottom of the page. All fields marked with "*" are mandatory.

Contact Information

First Name*:

Last Name*:

Address*:
City*:
Province/State*:
Postal/Zip Code*:

Country*:

Canada
United States
Phone Number*:
Mobile Number:
Fax Number:
E-Mail*:
Is this Membership a Renewal (yes or no)?:

Do You Belong To a CHHA Branch (specify)?:

Membership Information

Membership Type

Price

Personal Membership $30.00
Student Membership** $20.00
Family Membership $50.00
Lifetime Membership $350.00
Not-For-Profit Membership $120.00
Organizational Membership $300.00

*All rates are quoted in Canadian $$ and include tax.

**A student is defined as a holder of a student identification card from a recognized tertiary or secondary educational institution or international student card. Students must be studying full-time to qualify for the discounted rate. A copy of your student card must be faxed or emailed to us following the submission of your web form. Without this ID, the personal membership fee will be charged.

Payment Information

Credit Card

By paying by credit card, I understand that my credit card statement will show this transaction as "C.H.H.A" and I will ensure that anyone who reviews the statement is aware of the transaction.

Name on Credit Card:
Card Type:
Credit Card Number:
CVV Number:
Expiration Date: MM/ YY
Please provide billing address
Street number:
Street name:
Zip/Postal code:

Cheque

Please make your cheque payable to the "CHHA" and mail to:

Canadian Hard of Hearing Association
2415 Holly Lane, Suite 205
Ottawa, ON K1V 7P2

Questions?

If you have any questions about membership, please contact Karla Wilson by phone at 800-263-8068.