Membership Form

EXETER AND DISTRICT MENCAP SOCIETY
registered charity number 235930
ANNUAL SUBSCRIPTION £5

All data is confidential and treated in compliant with the Data Protection Act


TITLE______  SURNAME__________________________________________


FORENAME(S)__________________________________________________


ADDRESS______________________________________________________


_________________________________________Postcode_____________


Telephone Number ________________________________

E mail_________________________________________________________

If you would give us the following information it would be really helpful.

Are you a :-   

 (   )       Person with  a learning disability       
                     
 (   )       Parent of a person with a learning disability
                       
 (   )       Carer of a person with a learning disability
                       
 (   )       Other (please specify) __________________________________
                                 
 Date of Birth of Person with disability____________________________
                       
 Where do they/you attend for respite_______________________________

 Where do they/you
attend Day Centre                           _______________________________

Please tick where they/you are living:-
at home(  )    supported living (  )    residential care (  )

Annual Subscription £5 Total Enclosed  £_______________________

UK TAX PAYERS PLEASE COMPLETE AND SIGN BELOW

                 
Please treat as Gift Aid donations all qualifying gifts of money made
today (   )                    in the past 4 years (   )                         in the future (   )
please place a tick in all the brackets that apply

 I confirm that I have paid or will pay an amount equal to the amount of Income Tax and/or Capital Gains Tax for each year (6 April to 5 April) that is at least equal to the amount of tax that all charities or Community Amateur Sports clubs (CASCs) that I donate to will reclaim on my gifts for that tax year. I understand that other taxes such as VAT and Council Tax do not qualify. I understand the charity will reclaim 28p of tax on every £1 that I give up to 5 April 2008 and will reclaim 25p of tax on every £1 that I give on or after 6 April 2008.

Please notify the charity or CASC if you:-    
(a) Want to cancel this declaration
(b) Change your home address
(c) No longer pay sufficient tax on your income and/or capital gains.

If you pay income tax at the higher rate, you must include all your Gift Aid donations on your self assessment tax return if you want to receive the additional tax relief due to you.

Signed.......................................................................................        date...........................................

Please copy and paste to print off and return completed form with your payment to :-      
 Jenny Denham (Membership Secretary), Burleigh, 348 Pinhoe Road,
Exeter  EX4 8AF  Telephone:- 01392 - 460741  or E mail jenny@bakhatla.uk