Renewal Form

HSLDA CANADA MEMBERSHIP FORM

Please fill out the online form below. 
Note that if you are already on a monthly payment option, no further payment information is required. 
HSLDA Canada will treat this information with absolute confidentiality.
If you need help filling out this form, please contact our office at 519.913.0318 for assistance.
HSLDA Membership Details




**For Monthly or Lifetime memberships, no payment is needed. Please call the office if you wish to change payment options.

Primary Contact Information (The primary contact will receive HSLDA email notifications.)









Secondary Contact if not listed in account name above





**Is this number incorrect? Once your renewal is complete, you can update your info on your HSLDA Member Portal (members.hslda.ca) under "View my Household".


Update regarding Legal Action Against any of your children



Your Discount Group Details


*By choosing a Discount Group, you give HSLDA permission to confirm, with the registered HSLDA contact of that group, that your HSLDA membership is active. (For group insurance & discount purposes only, no other information will be shared.) 
Review your Membership and Payment Information





Payment Information









5 digit branch or transit #

3 digit institution #(not cheque #)

8-12 digits, include zeros but not dashes, etc

Sample cheque



Hidden Form Specific Fields








Values to Submit to IATS



Contact Information