Membership Application

First Name *

First Name

Last Name

Would you like to be added to CFAN's email distribution list? *

By selecting “yes” you are providing consent for CFAN to send you electronic messages, including newsletters, meeting notices, etc. Your email address will not be sold and/or used in any other way. Please note that you may withdraw your consent and unsubscribe at any time.

Yes

No

Membership Type *

See information on voting privileges below. Note: there is a maximum of one professional voting membership per organization/agency.

Personal Voting

Professional Voting

Non-Voting

Please check all that apply, I am a:

Person with FASD

Caregiver of someone with FASD

Parent or family member of someone with FASD

Professional in FASD sector

Professional in a related sector (e.g. homelessness, education)

Other

(Please note that the contact information you provide is kept confidential and is not used for any other purpose.)

By submitting this form, you consent to be entered into CFAN's register of members.