Membership Application « Regina Community Clinic

Number of Applicants

Applicant 1

Basic Info

First Name*

Last Name*

Date of Birth * (yyyy-mm-dd)

Sex *

Contact Info

Email *

Phone *

Phone Alternative

Address Info

Province *

City *

Address *

Postal *

Receive correspondence from the clinic *

Email

Not Interested

I do hereby make application for membership in the Community Health Services Association (Regina) Ltd. By checking the box it acts as a signature and makes application for membership. *

Summary

Membership Plan Type
Total

Payment Details

The Regina Community uses the transaction provider "Stripe" for website transactions. The billing name "Regina Community Clinic" will appear on your credit card statement.

We value your privacy. We will use the information you have provided to provide you with a response. We will protect your information and report to you immediately, in case of a breach. We will not sell or divulge your information to any other party. If you have questions about any of this, please direct them to: Regina Community Clinic at 306.543.7880.

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