Membership Sign-Up Form

Fields marked with "*" are required.

Agency Information

Please complete all sections. The address, general email address and website will be used to update member agencies on Abilities Manitoba’s website. Please note that your agency will be responsible to notify Abilities Manitoba of any changes to this information.

Agency Name *
Address *
City / Town *
Postal Code *
General Email Address *
Phone Number *
Website



Executive Director/CEO

Name *
Email Address *



Board President (optional)

Name
Email Address



Finance/Accounts Receivable

Complete this if you want invoices forwarded to someone other than the Executive Director.

Name
Email Address

 



Do you provide support to populations other than adults with intellectual disabilities? *

 Yes No

 

Please answer the below questions for services related only to adults with intellectual disabilities:

 

Number of Unionized Employees *
Number of Non-Unionized Employees *
Number of Direct Support Positions *
Union Involved
Year Organization Was Unionized
Total Number of Employees *

 

Types of services offered:

(and number of people per type of service) Enter 0 if not-applicable.

Day Services *
Respite *
Foster *
Supported Independent Living *
Residential Services *
Supported Employment*
Crisis Support *
Social Enterprise *
Other *

 

In which region(s) of Manitoba do you provide services? Please select all that apply by holding 'Ctrl' key and left clicking regions. *

Annual Operating Budget of Agency *

 



Who would you like to receive Abilities Manitoba emails?

Name
Title
Email

 

Name
Title
Email

 

Name
Title
Email

 

Name
Title
Email

 



Certification
I certify that this organization:


 

Membership Fees
Final approval of this membership application will be based on receipt of the applicable membership fee. Payment can be made by cheque or PayPal. An invoice will be sent to your agency shortly.
Membership Fee Structure

Budget Size Annual Fee
$0-$499,999 $75
$500,000-$999,999 $100
$1,000,000-$2,499,999 $150
$2,500,000-$4,999,999 $300
$5,000,000-$9,999,999 $500
$10,000,000+ $800