Membership Sign-up – Midwives Association of Manitoba

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Email(Required)

Membership Application

Name(Required)

First Last

Phone(Required)

Full Mailing Address(Required)

Street Address City Province Postal Code

Release of Information Consent:(Required)

I agree

As a member of MAM, I am fully aware that MAM will release my name and contact information to the Canadian Association of Midwives and to HIROC. Both of these agencies are integral components to my MAM membership.

PRIVACY STATEMENT:(Required)

I agree

MAM will not distribute my information to any other parties.

I confirm that this application is true.(Required)

Yes

This is my electronic signature.(Required)

First Last

Membership Type(Required)

HIROC APPLICATION

All questions in the HIROC application are required for Full and Non-Practicing members.

College Registration Number(Required)

RHA Employer(Required)

Practice Group Location(Required)

Street Address City Province Postal Code

Are you aware of any matters which may give rise to a claim not yet reported (i.e. college complaints, Privacy breach etc.)?(Required)

Yes

Report Known Matters(Required)

Agree

I confirm that I will report any previous matters to HIROC. Contact the MAM treasurer to request the HIROC reporting form midwivesofmanitoba@gmail.com

Reporting Changes(Required)

I agree

I agree that if any significant changes are discovered between the date of this application and effective date of the policy (January 1st), I will report the change immediately in writing to HIROC. This application does not bind the applicant or insurer to complete the insurance. It is agreed that this form is the basis of the contract if a policy is issued.

Payment & Membership Dues

All payments are made by credit card and are withdrawn on the 3rd day of the month, starting January 1st. If your credit card information changes or prevents automatic withdrawal, we will send you a notice. You can update us before the next payment is due and we will withdraw the full amount owing.

Fees(Required)

Student Membership ($48 annually – $4 monthly)

Full Membership Board Member ($750 annually – $62.50 monthly)

Full Membership ($850 annually – $70.75 monthly)

Non-practicing Membership ($498 annually – $41.50 monthly)

Fees (Logged in)(Required)

Paid with alternative method

Student Membership ($48 annually – $4 monthly)

Full Membership Board Member ($750 annually – $62.50 monthly)

Full Membership ($850 annually – $70.75 monthly)

Non-practicing Membership ($498 annually – $41.50 monthly)

Total

Automatic Renewal Info

Credit Card(Required)

Card Details

Cardholder Name

Full payment Agreement(Required)

I agree to pay my annual dues in full

Membership Form

Membership Application

HIROC APPLICATION

Payment & Membership Dues

Automatic Renewal Info