MEMBERSHIP FORM
Please use this form to:
- Become a member, to renew membership and/or to make a donation.
Please complete and return this application form (with cheque enclosed if paying that way – see below for methods of payment to Parkinson’s Association of Ireland, Carmichael House, North Brunswick Street, Dublin 7.
Please tick here: _ _ if you are a PAYE worker and are making a donation of €250 or more in one tax year, as we may be eligible for tax relief.
FEE: Full Membership: €25 per annum Associate Membership(Nominated Person -friend/family carer): Free
YOUR NAME ………………………………………….….……………….…………………………....Date of Birth:...... …………………………….
ADDRESS ……………………………………………….….……………….………………………………………………………………………………………….
…………………………………………………………………………………….…………………………………………………………………………………………
Tel. No(s) : ………………………………………… Email ……………..…………………………………………………………………………………..
Nominated Person’s Name (see above)………………………………..…………………………..……………………………………………………
ADDRESS (if different from yours) ……………………….…………………………………………………………………………………………………
………………………………………………………………………………………………….……………………………………………………………………………
Tel. No(s).: ……………………………………….. Email ……………………………………………………………..………………………………….
MEMBERSHIP TYPE –Please tick one
… . Branch (Note - you may attend any meeting of any branch)
… . General (no branch chosen –with the option of joining a branch when desired).
BRANCHES –Please tick your choice
… . Dublin … . Louth/Meath… . Cavan … . Donegal꙱ Longford
… . West (Galway)… . Midwest (Limerick)… . North Kerry… . South Kerry꙱ YPI
… . Tipperary… . Waterford… . Roscommon… . Mayo
… . Cork… . East Midlands… . Wexford … . Monaghan
DONATIONS IN ADDITION TO YOUR MEMBERSHIP FEE –
Please note this is optional but important as we get no core funding whatsoever from any of the statutory bodies.
I would like to make a donation to my Branch (Name of Branch) ……………………………………; of:
€ … .. [General]
I would like to make a donation to The National Office
€ …. . [General]; € …. . for Research
PAYMENT METHOD – Please choose one
If you would like to make a regular donation without membership, please ask us for a Donation-only Standing Order Form [TICK HERE TO REQUEST]… .
PAY by CHEQUE or POSTAL ORDER:
I/We enclose a cheque/ Postal Order in the amount of €…… . .…… made payable to “Parkinson’s Association of Ireland” to include membership fee and/or optional donations listed above.
PAY by CREDIT orDEBIT CARD
I hereby authorise payment of the amount of € … .. as detailed above [Membership Fee and/or Donations], to the Parkinson’s Association of Ireland.
Card Number
… . … . … . … . … . … . … . … . … . … . … . … . … . … . … . … . … . … . … . .
Valid from MM YY Expiry Date MM YY Security Code (last 3 digits on back of card)
… . … . … . … … . … . … . … . … . … . … . Name on Card….…………………………………………..………
Signature…………………………………...... Date……………………………………………..……….…
PAY by STANDING ORDER – for MEMBERSHIP FEE PAY ANNUALLY ONLY
To the Bank Manager [Name of Bank]…....……………………………………..………….…..……………………………………….………
Bank Branch Address………………………….……………………………………………………………………………………………………………
Name(s) of Account Holder(s)……………………………………………….……………………………………………….………………….…….
Account No: … . … . … . … . … . … . … . … . Sort Code No: … .… . … .… . … .… .
Please pay to the Parkinson’s Association of Ireland (Bank of Ireland, Smithfield, Dublin 7; A/C No. 11481057, Sort Code No. 90-00-92) to include Membership Fee and optional annual donations as specified above,
€ … .. commencing on date:……….………………..…. and annually thereafter as indicated until otherwise instructed. Please note that donations may be made quarterly or annually; membership annually only. Ask us for a quarterly Donation form if setting up a quarterly donation-only Standing Order!
Signature(s)…………………………………….…………………………………………… Date…………………………………………………………
ABOUT YOU (Optional)
… . I am a person with Parkinson’s, diagnosed in …………… (year) at age ……….….. (age at diagnosis).
I see a (circle as applicable) Neurologist or Geriatrician or other medical person(please specify)…………………………………….………………………………….…………… for my Parkinson’s.
… . I am a spouse/partner/carer/family member of a person with Parkinson’s.
… . I am a health professional
….. Other (please state) ………………………………………………………………….
… . I would like to volunteer for research. Please let me know of research projects for which I might be suitable. (We will not release your details without your permission, and note that both people with Parkinson’s and their families, as well as people with no connection to anyone with Parkinson’s are needed).
YOUR FEEDBACK
What services would you like to see us providing, given funding being available?
…………………………………………………………………………………………………….…………………………………………………………………………
……………………………………………………………………………………………………….………………….…..……………………………………………..
What PAI services do you use? … . - Helpline … . - Information leaflets … . - Parkinson’s Nurse
… . - Branch or National meetings … . - PAI Magazine … .- Other..……………………………….………...
NATIONAL FREEPHONE HELPLINE 1 800 359 359
The Parkinson’s Association of Ireland is a company with limited liability registered in Ireland: Co. No. 123532, and a registered charity: CHY No.10816. Registered address: Carmichael House, North Brunswick Street, Dublin 7.