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 RegistrationRenewalName 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 WebsiteOrganization Mission StatementNumber of Members as of April 1, 2021Does your organization have an elected community board?*YesNo#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 PositionPhoneEmail #3 Optional Contact InformationName First Last PositionPhoneEmail 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 OtherOther QuestionsPlease answer the following questions about your staffing and insurance.Does your organization have hired staff?*YesNoNumber 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?*YesNoAre any of your members/staff interested in Johnson Insurance?*YesNoUnsureMASC 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?*YesNoMASC Admin AreaHas this Member Paid?YesNoHas Membership Certificate Been Mailed?YesNoHiroc Insurance?YesNoNotes:
