Instructions: If you are paying by check, please do not fill out this online form. Download the PDF version of this form, fill it out and send it along with your payment. This online form is only for those who are paying online.

All Fields are required.

Last Name: 

Husband's Name: 

Wife's Name: 

Mailing Address: 

City:       State: 

Zip:       County: 

Home Phone (with area code):  - -

Email: 


Membership Type:  New    Renew

Are you a support group leader?:  Yes    No

Are you a member of HSLDA?:  Yes    No


Today's Date (dd/mm/yyyy format): 

CHEO Membership is $30 annually.

Donation to CHEO: $

Total Payment: $

Upon submittig this form you will be directed to our online store where you can make your payment.This is a two part registration process. You have just completed the first part.

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