MEMBERSHIP FORM

Name …………………………………………….

Address ………………………………………….

Post Code ………………………………………..

MEMBERSHIP CATEGORY

Annual £10 (or £40 for 5 Years) Family £15 Concession (over 60yrs) £5 Life Membership £100 Business £100 per year

BANKERS STANDING ORDER

To the Manager: …………………. (name of bank)
Branch Address: ………………………………….
………………………………Post Code ………….
Account Number …………………………………
Sort Code ………………………………………….
Please pay to the credit of:

Newcastle Children’s Hospital Charity,
Caf Bank,
25 Kings Hill Avenue,
Kings Hill,
West Maling,
Kent,
ME19 4JQ

Account Number 00010637, Sort Code 40-52-40
The sum of £……..(amount in figures) …………….. …………(amount in writing) annually, starting on ………..…. until amended or cancelled by me.
This instruction supersedes any previous instruction I have made for payments to the Newcastle Children’s Hospital Charity.

Signed ………………………………… Date …………
Name in Block Capitals ………………………………

Do you wish your subscription to be Gift Aided YES ( ) NO( )

Please return form to : Mrs Lesley Field 24 Polwarth Road Gosforth Newcastle upon Tyne NE3 5ND