MASC Membership/Renewal 2021-2022 Please fill in the from below to register your MASC Membership for 2021/2022. Fields noted with the red asterisk are required. Fields that do not apply to your organization may be left blank. New Registration or Renewal* New Registration Renewal Name of Organization* Organization Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Organization Phone*Organization Email* Organization Website Organization Mission StatementNumber of Members as of April 1, 2021Does your organization have an elected community board?* Yes No #1 Contact Information - Board Member/StaffName* First Last Position* PhoneEmail (If different than the email provided above.) #2 Contact Information - Board Member/StaffName First Last Position PhoneEmail #3 Optional Contact InformationName First Last Position PhoneEmail Current ActivitiesCurrent activities conducted by your organization. Check all that apply.Activities Health and Wellness Programs Education Programs Social Events Food Programs (congregate meals, special lunches, etc.) Transportation Services Support Groups Other Other Other QuestionsPlease answer the following questions about your staffing and insurance.Does your organization have hired staff?* Yes No Number of Full Time StaffPlease enter a number from 0 to 10.Number of Part Time StaffPlease enter a number from 0 to 10.Do you carry HIROC insurance offered through MASC?* Yes No Are any of your members/staff interested in Johnson Insurance?* Yes No Unsure MASC MembershipMASC's membership year runs from April1 - May 31. The $100 membership fee is due by May 31 of the membership year. (It is possible to prorate this fee for the first year only.) Cheque is to be made payable to MASC. Please ensure your centre/group name appears on the cheque. Forward with this application to: MASC Membership Attn: C Newman, Executive Director 3 - 203 Duffield Street Winnipeg, MB R3J 0H6Would You Like a Membership Certificate Mailed to You?* Yes No HiddenMASC Admin AreaHiddenHas this Member Paid? Yes No HiddenHas Membership Certificate Been Mailed? Yes No HiddenNotes:
