I want to join by printing the form below and mailing it in together with a cheque or money order.
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MEMBERSHIP FORM
RIGHT TO DIE SOCIETY OF CANADA

Name(s)

Address _______________________________________________________

______________________________________________________________

______________________________________________________________

Telephone ______ - ______ - _________

Fax, if any ______ - ______ - _________

E-mail _______________________________________________________________

I enclose a cheque or money order, payable to Right to Die Society of Canada, for

__ $30 (Regular-rate annual membership, single)

__ $40 (Regular-rate annual membership, couple or family)

(Cut the above amounts in half if you also belong to another death-with-dignity group)

__ $_____ (Special-circumstances reduced rate -- please add a brief note below:)

___________________________________________________________

___________________________________________________________

__ $_____ (Regular rate plus a gift, to help fund reduced-rate memberships for people with extremely low income or assets)

Right to Die Society of Canada
145 Macdonell Ave.
Toronto, Ontario
Canada
M6R 2A4