Membership Form

Name:(*)

Please type your name.

Organization Name (if representing a group):

Please type your organization name.

Contact Person(s):

Please type contact persons name.

Street address:(*)

Please type Street address.

Mailing address (if different from street address):

Please type mailing address.

Community(*)

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Postal Code(*)

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Telephone:(*)

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Fax:

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E-mail(*)

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Website Address:

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Please give a brief description of your organization:

Please give a brief description of your organization.

You will be involved in the Wellness Coalition by (check all that apply):(*)

Sharing your wellness news and events on Coalition newsletter and bulletins
Connecting with other members in the Coalition
Acting as a resource person in your area of knowledge
Promoting the Wellness Coalition-Avalon East
Suggest a role:

Please check all that apply.

Role Name(*)

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How did you hear about us?(*)

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For further information call (709)752-4912 or e-mail: heather.powell@easternhealth.ca

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Mount Pearl Square – Community Services
760 Topsail Road, Mount Pearl, NL A1N 3J5