Pacific Open Heart Association > Member Application

Please enter the following information, then click the Submit Member Application Form button.

The Membership Fee is only $10 per year. When you have completed the on-line Membership Application, please send a cheque in the amount of $10 to:

Pacific Open Heart Association
PO Box 45001
Ocean Park PO
Surrey, BC
V4A 9L1

Last Name

First Name

Address

City

Province/State

Postal/ZIP Code

Telephone Number (ie. 604-555-1234)

Email Address

Birth Date (ie. dd/MM/yyyy)

Surgery Date (ie. dd/MM/yyyy)

Surgery Hospital

Surgery Type

Remarks

Interested in being a hospital visitor?

Interested in being a POHA volunteer?

Interested in our golf tournament?