Asperger East Anglia Membership Application Form / Donation Form
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By supporting you would help to improve the lives of so many young people.

If you would like to join or donate to Asperger East Anglia, please print and fill in the form below

Membership costs are:
£20 per family, £50 professionals, or £10 concessions.
                
Title:    Forename:   Surname:
Address:
Post Code:
Telephone:
Name of child:
Age of child:
Diagnosis:
Membership fee enclosed:
Donation enclosed:
Total:
Please tick box to add Gift Aid (Link to details of Gift Aid)

I am a UK taxpayer and I want the charity to treat all my subscriptions, together with any donations I make as Gift Aid Donations. I want Asperger East Anglia to reclaim tax on all my subscriptions and donations from now onwards.
Signature:      Date:

Please make cheques payable to Asperger East Anglia
Please return to:

Asperger East Anglia
Charing Cross Centre
17/19 St John Maddermarket
Norwich
NR2 1DN
Telephone: (01603) 620500

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