Complete the Form below to purchase a membership, parking pass or mailout newsletter A Membership, Newsletter, Parking Registration 2018/19 I would like to register for the following at the St. James Assiniboia 55+ Centre* Membership Newsletter Parking Pass Membership Type*RenewalNew MemberNewsletter Choice*Prefer newsletter by emailWill pick up newsletter at the centreI would like it to be mailed to my home for $15/yearIf you would prefer the newsletter via Canada Post there is an annual fee of $15.00. There is no fee to pick up the newsletter at the Centre and/or to receive via email. Virtual Parking Pass*Annual Parking Pass $5.00No Thank You ParkingThe cost of an annual parking pass for the Centre is $5.00 and is valid from January 1st to December 31st 2019.My Licence Plate Number is?*Please Note: To avoid a parking ticket, double check and ensure you have entered the correct vehicle licence plate number. Name* First Last Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Email If you do not have an email address please leave blankHome Phone*Cell or Other PhoneEmergency Contact InformationEmergency Contact Name* First Last Emergency Contact PhoneEmergency Contact Relationship to YouMembership Release Clause Agreement for St. James Assiniboia 55+ Centre: In consideration of my acceptance as a member, participant, and/or volunteer of the Centre, I do hold harmless the Centre, its Directors, officers and personnel engaged in or volunteering to conduct the Centre’s activities, from any and all liability for any claim, demand, suits or clauses of action growing out of or in any way attributable to any injuries, including death, damage or loss to me whatsoever, arising out of or connected with the conduct of the Centre’s property or facilities.I have read and understood the Membership Release Clause*YesPayment Options*Pay OnlinePay at the CentreThe "Pay at the Centre" option should only be selected when purchasing Membership, Parking and/or Newsletter options while in person at the St. James Assiniboia 55+ Centre. Note: Virtual Parking Passes take effect 24 hours (1 Business Day) after payment has been received.Payment Type Cash Cheque Visa Mastercard Debit Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Total $ 0.00 CAD This iframe contains the logic required to handle Ajax powered Gravity Forms.