BC Health Coalition — Membership / Donation Form

Yes! I want to support the BC Health Coalition and help protect public health care in British Columbia.

Contact Information

Name: ______________________________________________
Organization (if applicable): _____________________________
Address: ____________________________________________
____________________________________________________
Postal Code: ______________
Email: ______________________________________________
Phone: ______________________________________________
* Email is important so we can keep you updated on our work throughout the year.

Donation Options

I would like to:
☐ Become a Monthly Donor
☐ Make a One-Time Donation

Monthly Donation Amount:
☐ $5   ☐ $10   ☐ $20   ☐ $25   ☐ Other: $________
☐ I have enclosed a VOID cheque for monthly donations
☐ Please charge my credit card (Visa/MasterCard) monthly

One-Time Donation Amount: $________
☐ I have enclosed a cheque (made out to BC Health Coalition)
☐ Please charge my credit card (Visa/MasterCard)

Credit Card Number: __________________________________________________________________
Expiry Date (MM/YY): ______ / ______
Name on Card: ________________________________

Signature (REQUIRED): ________________________________

Membership Options

Individual Membership Fee: $10
☐ I would like to become a member of the BC Health Coalition
Total Enclosed (Membership + Donation): $__________

Organizational Membership

We would like to become an Organizational Member of the BC Health Coalition.
We support BCHC’s mission, values, and the Call to Care of the Canadian Health Coalition.

Fee Structure for Organizations:
Community Groups / Union Locals / “Part of Larger Groups”
  - Under 100 members – $25/year
  - 101–1,000 members – $50/year
  - 1,001 and over – $75/year

Provincial or Regional Organizations:
  - Under 1,000 members – $50/year
  - 1,001–10,000 members – $100/year
  - Over 10,000 members – $500/year

Organizational Membership Fee: $__________
Additional Donation: $__________   ☐ For Operations   ☐ For Campaigns

Total Enclosed: $__________

Please Mail Completed Form & Payment to:

BC Health Coalition
302–3102 Main Street
Vancouver, BC V5T 3G7

🌐 www.bchealthcoalition.ca
📧 [email protected]