PwNC Membership

NEURO THERAPY CENTRE MEMBERSHIPSUBSCRIPTION

Registered Charity Number - 700904

Date:Membership Number:

Title & Full Name:______

Address:______

______Postcode: ______

Home Phone:______

Mobile: ______

Email: ______

NHS Number:Date of Birth:

Carers Details: / Name:
Phone no:
Relationship to you:

Emergency Contact Details(if different from above):

Contact Name:Contact phone no:

Health Authority, please tick:

West Cheshire / Betsi Cadwaladr / Eastern Cheshire / Wirral
Liverpool / Other (please state):

Doctor:

Doctor’s Name
Practice Name

Please turn over……..

Conditions, please tick:

MS / Parkinsons / MND / ME / Fibromyalgia
Other conditions, please specify:

Ethnicity (please tick):

White European / Asian Chinese / Black African
White Irish / Asian Indian / Black Caribbean
White Other / Asian Bangladeshi / Black Other
Asian Other / Asian Pakistani / Other
Membership Fee: / Individual Member / £20
One Off Donation
Total

Please make cheques payable to “Neuro Therapy Centre”, you can also pay by cash or card at the Centre

IF YOU ARE A TAX PAYER PLEASE COMPLETE A GIFT AID FORM

Consent
If you would like to be kept up-to-date with Centre activities and receive the Centre Newsletters please tick here
If you wish to receive email communication relating to the Centre please tick here
If you are happy to appear in Neuro Therapy Centre photography used to support fundraising and the promotion of the Centre, please tick here
You can withdraw your consent for any of the above by either by clicking opt-out at the end of the emails or by contacting Melanie Kane on or 01244 678619.

For NTC use:

Paid by: Cash Cheque CardBACSDate of payment:

Neuro Therapy Centre, Unit C4 Brymau Estate 1, River Lane,Saltney, Near Chester CH4 8RG

Telephone 01244 678619 e-mail: Reg Charity Number 700904

GIFT AID DECLARATION

As a registered charity the Neuro Therapy Centre can claim gift aid on both donations and your membership fee if you are a tax payer.

This will boost your donation by 25p in every £1 you donate.

Title & Full Name: ______

Address:______

______

Postcode: ______

GIFT AID FORM
In order to Gift Aid your donation you must tick the box below:
I want to Gift Aid all qualifying donations I make today and in the future
I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax in the current tax year than the amount of Gift Aid claimed on all my donations it is my responsibility to pay any difference.
Please notify the Charity if you:
Want to cancel this declaration / Change your name or home address / No longer pay sufficient tax on your
income and/or capital gains
If you pay Income Tax at the higher or additional rate and want to receive the additional tax relief due to you, you must include all your Gift Aid donations on your Self-Assessment tax return or ask HM Revenue and Customs to adjust your tax code.
Signature………………………………………………..……..…. Date……../………/……….

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