Aphasia Nova Scotia Membership Form

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By completing this form you will be considered a member of Aphasia Nova Scotia. As a member you will be added to an email list and receive updates about the organization and will be invited to attend our Annual General Meeting.

First Name: *

Last Name: *

Email address: *

Phone Number: *

Area of Residence *

HRM

South Shore

Annapolis Valley

Cape Breton

Yarmouth/Digby Area

Truro Area

Antigonish Area

Other:

If you chose other above, please specify where you live:

Do you consent to receiving emails from Aphasia Nova Scotia? *

Yes

Aphasia Nova Scotia is open to anyone.

How are you connected to the Aphasia Community? *

Individual with Aphasia

Family member/friend of an individual with aphasia

Interested in supporting the Aphasia Community

How would you like to be involved with the organization?

Submit

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