FULL INDIVIDUAL MEMBERSHIP

APPLICATION FORM

Name:

Address & postcode:

Telephone:

Email:

How did you hear about becoming a member of Disability Cornwall and IOS? ______

As a user led charity our constitution states that 51% of our membership must have an illness or impairment.

It would be useful to learn the needs of our members to ensure we cover relevant information in Discover magazine, if you would not mind stating, what type of illness or impairment you regard yourself as having: (please tick)

Learning difficulties  Mental health issues Physical impairment  Sensory impairment 

and / or state the nature of your disability______

Due to environmental concerns, where possible, we would like to contact you by email as opposed to post. Would you be happy for us to do this?

Yes  No 

Join the ‘DC100’

We aim to recruit 100 disabled people who are available via email to give us quick and brief feedback on issues of concern; we will be calling them our ‘DC100.’

This is to obtain the views of disabled people to ensure we are acting in a truly representative way, guarantee disabled people’s voices are heard and help to shape future service provision, for example; whether the closure of rural post offices would negatively impact on your quality of life.

Would you be interested in being one of the DC100 for a period of one year?

Yes  No 

Mailing

Cornwall Council has offered to support us by sending out some of our mail which would otherwise incur a significant cost to the charity. Therefore, we may pass on to them printed address labels for applying to the envelopes.

Please tick here if you are opposed to this  …………….pto

Gift Aid

Should you wish to make a donation to the charity all donations are gratefully received. If you are a taxpayer you can increase your contribution to the charity by simply signing the form below!

Are you a taxpayer?

If the answer is Yes please tick this box ÿ so that we can re-claim the tax back from your donation.

I want the charity to treat…

·  the enclosed donation of £ ______

·  the donation(s) of £ ______which I made on ___/___/___

·  all donations I make from the date of this declaration until I notify you otherwise.

·  All donations I have made since 6 April 2000 and all donations I make from the date of this declaration until I notify you otherwise.

…as Gift Aid donations.

Please indicate your payment method.

Cheque BACS (Account 00082346 Sort 40-52-40)

Signed ______Date______

Notes:

You must pay an amount of income tax and / or capital gains tax at least equal to the tax that we reclaim on your donations in the tax year (currently 28p for each £1 you give.)

You can cancel this declaration at any time by notifying us.

If in the future your circumstances change and you no longer pay tax on your income and capital gains tax equal to the tax that we reclaim, you can cancel your declaration

If you pay tax at the higher rate you can claim further tax relief in your Self-Assessment tax return.

If you are unsure whether your donations qualify for Gift Aid, please ask us or ask your local tax office for leaflet IR 65.

Membership is £20 per year for disabled people living outside of Cornwall.

We look forward to welcoming you as a member soon!

Please sign below and return this form to:

Disability Cornwall and IOS Ltd,

Unit 1G/H

Guildford Road Industrial Estate

Hayle

Cornwall

TR27 4QZ.

Signed:……………………………………… Date:………..………