{"id":2677,"date":"2017-05-12T15:08:46","date_gmt":"2017-05-12T15:08:46","guid":{"rendered":"http:\/\/student36.silkwebsolutions.com\/?page_id=2677"},"modified":"2019-09-06T15:56:55","modified_gmt":"2019-09-06T15:56:55","slug":"membership-form","status":"publish","type":"page","link":"https:\/\/oldsite.chha.ca\/fr\/get-involved\/membership\/membership-form\/","title":{"rendered":"Membership Form"},"content":{"rendered":"<p class=\"qtranxs-available-languages-message qtranxs-available-languages-message-fr\">D\u00e9sol\u00e9, cet article est seulement disponible en <a href=\"https:\/\/oldsite.chha.ca\/en\/wp-json\/wp\/v2\/pages\/2677\" class=\"qtranxs-available-language-link qtranxs-available-language-link-en\" title=\"English\">Anglais Am\u00e9ricain<\/a>. Pour le confort de l\u2019utilisateur, le contenu est affich\u00e9 ci-dessous dans une autre langue. Vous pouvez cliquer le lien pour changer de langue active.<\/p>[vc_row][vc_column width=&#8221;2\/3&#8243;][vc_column_text]Any person who supports CHHA\u2019s objectives may become a member. Joining CHHA is easy and affordable. Please complete the form below to purchase your CHHA membership.[\/vc_column_text]\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_3' ><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/fr\/wp-json\/wp\/v2\/pages\/2677'>\n                        <div class='gform_body'><ul id='gform_fields_3' class='gform_fields top_label form_sublabel_above description_above'><li id='field_3_27'  class='gfield gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible' ><label class='gfield_label'  >Type of Membership<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_27'><li class='gchoice_3_27_0'><input name='input_27' type='radio' value='New Membership'  id='choice_3_27_0'    \/><label for='choice_3_27_0' id='label_3_27_0'>New Membership<\/label><\/li><li class='gchoice_3_27_1'><input name='input_27' type='radio' value='Renewal'  id='choice_3_27_1'    \/><label for='choice_3_27_1' id='label_3_27_1'>Renewal<\/label><\/li><\/ul><\/div><\/li><li id='field_3_5'  class='gfield gf_left_half gfield_price gfield_price_3_10 gfield_option_3_10 gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_3_5' >Please choose the type of membership you would like.<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_5' id='input_3_5' class='medium gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='Personal|30' >Personal<\/option><option value='Student|20' >Student<\/option><option value='Family|50' >Family<\/option><option value='Not-for-Profit|120' >Not-for-Profit<\/option><option value='Organization|300' >Organization<\/option><option value='Lifetime|350' >Lifetime<\/option><\/select><\/div><\/li><li id='field_3_10'  class='gfield gf_left_half gform_hidden gfield_price gfield_price_3_10 gfield_product_3_10 gfield_hidden_product field_sublabel_above field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_3_10_1' >Membership<\/label><input type='hidden' name='input_10.3' value='1' id='ginput_quantity_3_10' class='gform_hidden' \/><input type='hidden' name='input_10.1' value='Membership' class='gform_hidden' \/><input name='input_10.2' id='ginput_base_price_3_10' type='hidden' value='$ 0.00 CAD' class='gform_hidden ginput_amount' \/><\/li><li id='field_3_20'  class='gfield gfield_price gfield_price_3_ gfield_total gfield_total_3_ field_sublabel_above field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_3_20' >Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t<span class='ginput_total ginput_total_3' aria-live='polite'>$ 0.00 CAD<\/span>\n\t\t\t\t\t\t<input type='hidden' name='input_20' id='input_3_20' class='gform_hidden'\/>\n\t\t\t\t\t<\/div><\/li><li id='field_3_22'  class='gfield gsection field_sublabel_above field_description_above gfield_visibility_visible' ><h2 class='gsection_title'>Personal Information<\/h2><\/li><li id='field_3_2'  class='gfield gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Name<span class='gfield_required'>*<\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_3_2'>\n                            \n                            <span id='input_3_2_3_container' class='name_first' >\n                                                    <label for='input_3_2_3' >Pr\u00e9nom<\/label>\n                                                    <input type='text' name='input_2.3' id='input_3_2_3' value='' aria-label='Pr\u00e9nom'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                <\/span>\n                            \n                            <span id='input_3_2_6_container' class='name_last' >\n                                                            <label for='input_3_2_6' >Nom<\/label>\n                                                            <input type='text' name='input_2.6' id='input_3_2_6' value='' aria-label='Nom'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/li><li id='field_3_3'  class='gfield field_sublabel_above field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_3_3' >\n                         <span class='ginput_full address_line_1' id='input_3_3_1_container' >\n                                        <label for='input_3_3_1' id='input_3_3_1_label' >Adresse postale<\/label>\n                                        <input type='text' name='input_3.1' id='input_3_3_1' value=''    \/>\n                                    <\/span><span class='ginput_full address_line_2' id='input_3_3_2_container' >\n                                        <label for='input_3_3_2' id='input_3_3_2_label' >Adresse ligne 2<\/label>\n                                        <input type='text' name='input_3.2' id='input_3_3_2' value=''   \/>\n                                    <\/span><span class='ginput_left address_city' id='input_3_3_3_container' >\n                                    <label for='input_3_3_3' id='input_3_3_3_label' >Ville<\/label>\n                                    <input type='text' name='input_3.3' id='input_3_3_3' value=''    \/>\n                                 <\/span><span class='ginput_right address_state' id='input_3_3_4_container' >\n                                        <label for='input_3_3_4' id='input_3_3_4_label' >\u00c9tat \/ Province \/ R\u00e9gion<\/label>\n                                        <input type='text' name='input_3.4' id='input_3_3_4' value=''      \/>\n                                      <\/span><span class='ginput_left address_zip' id='input_3_3_5_container' >\n                                    <label for='input_3_3_5' id='input_3_3_5_label' >ZIP \/ Code postal<\/label>\n                                    <input type='text' name='input_3.5' id='input_3_3_5' value=''    \/>\n                                <\/span><span class='ginput_right address_country' id='input_3_3_6_container' >\n                                        <label for='input_3_3_6' id='input_3_3_6_label' >Pays<\/label>\n                                        <select name='input_3.6' id='input_3_3_6'   ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Afrique du Sud' >Afrique du Sud<\/option><option value='Albanie' >Albanie<\/option><option value='Alg\u00e9rie' >Alg\u00e9rie<\/option><option value='Allemagne' >Allemagne<\/option><option value='Andorre' >Andorre<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctique' >Antarctique<\/option><option value='Antigua-et-Barbuda' >Antigua-et-Barbuda<\/option><option value='Arabie Saoudite' >Arabie Saoudite<\/option><option value='Argentine' >Argentine<\/option><option value='Arm\u00e9nie' >Arm\u00e9nie<\/option><option value='Aruba' >Aruba<\/option><option value='Australie' >Australie<\/option><option value='Autriche' >Autriche<\/option><option value='Azerba\u00efdjan' >Azerba\u00efdjan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahre\u00efn' >Bahre\u00efn<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Belarus' >Belarus<\/option><option value='Belgique' >Belgique<\/option><option value='Belize' >Belize<\/option><option value='Bermudes' >Bermudes<\/option><option value='Bhoutan' >Bhoutan<\/option><option value='Bolivie' >Bolivie<\/option><option value='Bonaire, Saint-Eustache et Saba ' >Bonaire, Saint-Eustache et Saba <\/option><option value='Bosnie-Herz\u00e9govine' >Bosnie-Herz\u00e9govine<\/option><option value='Botswana' >Botswana<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Br\u00e9sil' >Br\u00e9sil<\/option><option value='Bulgarie' >Bulgarie<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9nin' >B\u00e9nin<\/option><option value='Cambodge' >Cambodge<\/option><option value='Cameroun' >Cameroun<\/option><option value='Canada' selected='selected'>Canada<\/option><option value='Cap-Vert' >Cap-Vert<\/option><option value='Chili' >Chili<\/option><option value='Chine' >Chine<\/option><option value='Chypre' >Chypre<\/option><option value='Colombie' >Colombie<\/option><option value='Comores' >Comores<\/option><option value='Cor\u00e9e du Nord' >Cor\u00e9e du Nord<\/option><option value='Cor\u00e9e du Sud' >Cor\u00e9e du Sud<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatie' >Croatie<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='C\u00f4te d\u2019Ivoire' >C\u00f4te d\u2019Ivoire<\/option><option value='Danemark' >Danemark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominique' >Dominique<\/option><option value='Espagne' >Espagne<\/option><option value='Estonie' >Estonie<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Fidji' >Fidji<\/option><option value='Finlande' >Finlande<\/option><option value='France' >France<\/option><option value='Gabon' >Gabon<\/option><option value='Gambie' >Gambie<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Grenade' >Grenade<\/option><option value='Groenland' >Groenland<\/option><option value='Gr\u00e8ce' >Gr\u00e8ce<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guin\u00e9e' >Guin\u00e9e<\/option><option value='Guin\u00e9e \u00e9quatoriale' >Guin\u00e9e \u00e9quatoriale<\/option><option value='Guin\u00e9e-Bissau' >Guin\u00e9e-Bissau<\/option><option value='Guyane' >Guyane<\/option><option value='Guyane' >Guyane<\/option><option value='G\u00e9orgie' >G\u00e9orgie<\/option><option value='Ha\u00efti' >Ha\u00efti<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hongrie' >Hongrie<\/option><option value='Inde' >Inde<\/option><option value='Indon\u00e9sie' >Indon\u00e9sie<\/option><option value='Irak' >Irak<\/option><option value='Iran' >Iran<\/option><option value='Irlande' >Irlande<\/option><option value='Islande' >Islande<\/option><option value='Isra\u00ebl' >Isra\u00ebl<\/option><option value='Italie' >Italie<\/option><option value='Jama\u00efque' >Jama\u00efque<\/option><option value='Japon' >Japon<\/option><option value='Jersey' >Jersey<\/option><option value='Jordanie' >Jordanie<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kirghizistan' >Kirghizistan<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kowe\u00eft' >Kowe\u00eft<\/option><option value='La Barbade' >La Barbade<\/option><option value='La R\u00e9union' >La R\u00e9union<\/option><option value='Lesotho' >Lesotho<\/option><option value='Lettonie' >Lettonie<\/option><option value='Liban' >Liban<\/option><option value='Liberia' >Liberia<\/option><option value='Libye' >Libye<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituanie' >Lituanie<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Mac\u00e9doine' >Mac\u00e9doine<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malaisie' >Malaisie<\/option><option value='Malawi' >Malawi<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malte' >Malte<\/option><option value='Maroc' >Maroc<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritanie' >Mauritanie<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexique' >Mexique<\/option><option value='Micron\u00e9sie' >Micron\u00e9sie<\/option><option value='Moldavie' >Moldavie<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolie' >Mongolie<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mont\u00e9n\u00e9gro' >Mont\u00e9n\u00e9gro<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibie' >Namibie<\/option><option value='Nauru' >Nauru<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nig\u00e9ria' >Nig\u00e9ria<\/option><option value='Niu\u00e9' >Niu\u00e9<\/option><option value='Norv\u00e8ge' >Norv\u00e8ge<\/option><option value='Nouvelle-Cal\u00e9donie' >Nouvelle-Cal\u00e9donie<\/option><option value='Nouvelle-Z\u00e9lande' >Nouvelle-Z\u00e9lande<\/option><option value='N\u00e9pal' >N\u00e9pal<\/option><option value='Oman' >Oman<\/option><option value='Ouganda' >Ouganda<\/option><option value='Ouzb\u00e9kistan' >Ouzb\u00e9kistan<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Panama' >Panama<\/option><option value='Papouasie-Nouvelle-Guin\u00e9e' >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value='Paraguay' >Paraguay<\/option><option value='Pays-Bas' >Pays-Bas<\/option><option value='Philippines' >Philippines<\/option><option value='Pologne' >Pologne<\/option><option value='Polyn\u00e9sie fran\u00e7aise' >Polyn\u00e9sie fran\u00e7aise<\/option><option value='Porto Rico' >Porto Rico<\/option><option value='Portugal' >Portugal<\/option><option value='P\u00e9rou' >P\u00e9rou<\/option><option value='Qatar' >Qatar<\/option><option value='Roumanie' >Roumanie<\/option><option value='Royaume-Uni' >Royaume-Uni<\/option><option value='Russie' >Russie<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9publique Dominicaine' >R\u00e9publique Dominicaine<\/option><option value='R\u00e9publique centrafricaine' >R\u00e9publique centrafricaine<\/option><option value='R\u00e9publique du Congo' >R\u00e9publique du Congo<\/option><option value='R\u00e9publique d\u00e9mocratique du Congo' >R\u00e9publique d\u00e9mocratique du Congo<\/option><option value='R\u00e9publique d\u00e9mocratique populaire du Laos' >R\u00e9publique d\u00e9mocratique populaire du Laos<\/option><option value='R\u00e9publique tch\u00e8que' >R\u00e9publique tch\u00e8que<\/option><option value='Sahara occidental' >Sahara occidental<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre et Miquelon' >Saint Pierre et Miquelon<\/option><option value='Saint-Christophe-et-Nevis' >Saint-Christophe-et-Nevis<\/option><option value='Saint-Marin' >Saint-Marin<\/option><option value='Saint-Si\u00e8ge' >Saint-Si\u00e8ge<\/option><option value='Saint-Vincent-et-les Grenadines' >Saint-Vincent-et-les Grenadines<\/option><option value='Sainte H\u00e9l\u00e8ne' >Sainte H\u00e9l\u00e8ne<\/option><option value='Sainte-Lucie' >Sainte-Lucie<\/option><option value='Salvador' >Salvador<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa am\u00e9ricaines' >Samoa am\u00e9ricaines<\/option><option value='Sao Tom\u00e9 et Principe' >Sao Tom\u00e9 et Principe<\/option><option value='Serbie' >Serbie<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapour' >Singapour<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovaquie' >Slovaquie<\/option><option value='Slov\u00e9nie' >Slov\u00e9nie<\/option><option value='Somalie' >Somalie<\/option><option value='Soudan' >Soudan<\/option><option value='Soudan du Sud' >Soudan du Sud<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Suisse' >Suisse<\/option><option value='Suriname' >Suriname<\/option><option value='Su\u00e8de' >Su\u00e8de<\/option><option value='Syrie' >Syrie<\/option><option value='S\u00e9n\u00e9gal' >S\u00e9n\u00e9gal<\/option><option value='Tadjikistan' >Tadjikistan<\/option><option value='Tanzanie' >Tanzanie<\/option><option value='Ta\u00efwan' >Ta\u00efwan<\/option><option value='Tchad' >Tchad<\/option><option value='Terres Australes Fran\u00e7aises' >Terres Australes Fran\u00e7aises<\/option><option value='Territoire britannique de l\u2019oc\u00e9an Indien' >Territoire britannique de l\u2019oc\u00e9an Indien<\/option><option value='Tha\u00eflande' >Tha\u00eflande<\/option><option value='Timor oriental' >Timor oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinit\u00e9 et Tobago' >Trinit\u00e9 et Tobago<\/option><option value='Tunisie' >Tunisie<\/option><option value='Turkm\u00e9nistan' >Turkm\u00e9nistan<\/option><option value='Turquie' >Turquie<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Ukraine' >Ukraine<\/option><option value='Uruguay' >Uruguay<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis et Futuna' >Wallis et Futuna<\/option><option value='Y\u00e9men' >Y\u00e9men<\/option><option value='Zambie' >Zambie<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c9gypte' >\u00c9gypte<\/option><option value='\u00c9mirats arabes unis' >\u00c9mirats arabes unis<\/option><option value='\u00c9quateur' >\u00c9quateur<\/option><option value='\u00c9rythr\u00e9e' >\u00c9rythr\u00e9e<\/option><option value='\u00c9tat palestinien' >\u00c9tat palestinien<\/option><option value='\u00c9tats-Unis' >\u00c9tats-Unis<\/option><option value='\u00c9thiopie' >\u00c9thiopie<\/option><option value='\u00cele Bouvet' >\u00cele Bouvet<\/option><option value='\u00cele Christmas' >\u00cele Christmas<\/option><option value='\u00cele Maurice' >\u00cele Maurice<\/option><option value='\u00cele Norfolk' >\u00cele Norfolk<\/option><option value='\u00cele de G\u00e9orgie du Sud' >\u00cele de G\u00e9orgie du Sud<\/option><option value='\u00cele de Man' >\u00cele de Man<\/option><option value='\u00celes Cayman' >\u00celes Cayman<\/option><option value='\u00celes Cocos' >\u00celes Cocos<\/option><option value='\u00celes Cook' >\u00celes Cook<\/option><option value='\u00celes Falkland' >\u00celes Falkland<\/option><option value='\u00celes F\u00e9ro\u00e9' >\u00celes F\u00e9ro\u00e9<\/option><option value='\u00celes Heard et McDonald' >\u00celes Heard et McDonald<\/option><option value='\u00celes Mariannes du Nord' >\u00celes Mariannes du Nord<\/option><option value='\u00celes Marshall' >\u00celes Marshall<\/option><option value='\u00celes Pitcairn' >\u00celes Pitcairn<\/option><option value='\u00celes Salomon' >\u00celes Salomon<\/option><option value='\u00celes Turques et Ca\u00efques' >\u00celes Turques et Ca\u00efques<\/option><option value='\u00celes Vierges am\u00e9ricaines' >\u00celes Vierges am\u00e9ricaines<\/option><option value='\u00celes Vierges britanniques' >\u00celes Vierges britanniques<\/option><option value='\u00celes de Svalbard et Jan Mayen' >\u00celes de Svalbard et Jan Mayen<\/option><option value='\u00celes mineures am\u00e9ricaines' >\u00celes mineures am\u00e9ricaines<\/option><option value='\u00celes \u00c5land' >\u00celes \u00c5land<\/option><\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_3_8'  class='gfield gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_3_8' >Email<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_8' id='input_3_8' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" \/>\n                        <\/div><\/li><li id='field_3_30'  class='gfield field_sublabel_above field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_3_30' >Phone\/Mobile<\/label><div 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