This form can be used to apply for membership or update your contact information. *

I want to become a new member.

I am already a member. Please update my details as provided.

Name *

First Name

Last Name

Address

Please provide a mailing address if you wish to receive correspondence through Canada Post (optional). Some fields in the Address block indicate “required”. If you choose to enter an address, it must be complete. The entire Address section is, however, optional.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

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Birthday

Helpful for determining age group of members (optional).

MM

DD

YYYY

I am interested in SAMPS as a: *

Patient

Caregiver

Medical Professional

Other

Prefer not to say

Date of Diagnosis

Helpful for statistical purposes (optional).

MM

DD

YYYY

Contact Home Phone Number

(###)

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Contact Cell Phone Number

(###)

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SAMPS sends communications via email to members regarding Support Group Meetings, Special Events, the AGM, Conference, Advocacy, Research Advancements and more. Confirm with the checkbox below that you consent to receive these communications. If at any time you wish to unsubscribe, you may do so by following the directions provided in the email communications. All information is private and confidential. It will not be shared with other parties. *

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