Membership Form

Online Membership Sign Up and Payment Form

For lifetime membership, or any questions please contact the Community Engagement Team at 604-408-7260 or email [email protected] for further information.

Membership Option

Membership Type and Cost

This is a

Membership # (if known)

Contact Information

First Name

Last Name

Address

City

Province

Postal Code

Phone

Comments

Help Us Cover Costs

Simply leave "Yes!" checked below to ensure that 100% of your intended donation is available for our mission.

Yes! I want $20.00 to go to S.U.C.C.E.S.S. BC and I will donate $20.60.No. I will donate $20.00 and S.U.C.C.E.S.S. BC will cover the processing costs.

Credit Card Information

Card Holder Name

Card Account Number

Expiration Date

Security Code

Billing Address

Same As Above

Address

City

Province

Postal Code

Privacy Policy
We take precautions to protect your information. We collect credit card or bank account information, names, addresses, and other data related to your transaction when you make a payment through our site. We use this information to process your payment.

Terms/Conditions
By submitting your payment, you authorize us to charge the account above for the amount specified in the Transaction Amount field. Account information for Recurring Pledges/Monthly Giving is encrypted and stored securely via SafeSave™ for automatic processing of your future payments. Notify us at anytime if you wish to discontinue your pledge.