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Membership Form

Please enter my membership in Bermuda Cancer and Health Centre, fees will go towards our goal of raising $750,000 to upgrade diagnostic equipment and patient support systems; thereby increasing early cancer detection and decreasing the time between screening and diagnosis.

Upon completion of this form you will be taken to the payment page.

All fields marked with a star are mandatory

Membership Form

Type of MembershipAnnual_Member $15 Life_Member $100
TitleDr Mr Mrs Miss Ms Lady Other
First Name
Last Name

Override the Name on Credit Card

Name on Credit Card

This should be the name on the Credit Card with which you are using to donate - if that is different to your name, you can override this value by checking the override box above.

Email Address
Home Phone Number
Work Phone Number
Cell Phone Number
Fax Number

I would like to receive the Bermuda Cancer and Health Newsletter

Mailing Address

PO Box
Building Name
Street Address
Parish
Post Code

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