Membership Application

Dues cover calendar year July 1st to June 30th

Name *

Date of Birth *

Name of Group Home (if applicable)

Address *

City *

Postal Code *

Email *

Home Phone

Cell Phone

Gender *

Male

Female

Self Identify

Type of Member *

Individual

Family

Group Home

Contact Name *

Relationship *

Home Phone

Cell Phone

I agree to be photographed and give ICHA the use of photos in all marketing & social media *

YES

NO

Applicant's Signature *

Date *

Guardian's Signature (If member is under 18yrs of age)

Date

Print Name of Guardian and relationship

Cell/contact #

Office and Program Hours

Monday-Thursday:

4:00 PM to 8:00 PM

ICHA is a Non-profit, Charitable Organization

BN 894402981RR0001

Novelletto Rosati Sports Complex

3939 Carmichael Road
Windsor, Ontario
N9C 0C3

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