Member Intake Form

To the Membership Applicant

VARCS membership is only for those who are HIV+ (they can have other issues but as long as HIV is one of them). Members automatically go on our newsletter (VARCS Beat) subscription list.

To become a member, fill in this form or if you would feel more comfortable talking to a real person call to set up an appointment to come in and register. You may also register over the phone. Contact information.

There is no cost for membership.

Your Contact Information

Name

Address

Postal Code

E-mail

Home Phone

Work Phone

Is it okay to call you at work? Yes No

Date of Birth

SIN

Income

Regular Welfare Disability II CCP Employed Other

Nutritional Supplement Schedule C

Next of Kin

Name

Phone

Medical Information

Family Doctor

Phone

HIV Specialist

Phone

All Medications:

Medical conditions

Office use

Confirmed: _____________________________ Code: __________________________