White Lodge Centre – Supporters Club
To join the Club, please
print and complete this form and return to:
White Lodge Centre,
Holloway Hill, Chertsey, KT16 0AE
Annual subscription is £15
payable by cheque or bankers order made out to
'White Lodge Supporters Club'. Prize
draw: £25 every month and £150 twice a year.
All proceeds from the Club are given to the White Lodge Centre Director at the AGM.
I wish to apply for membership
to the White Lodge Supporters Club and will subscribe £15
for each name annually until I give written notice terminating my membership.
| Full Name: (block capitals): | |
Address: |
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| Tel No: | |
| Signature: | Date: |
I want White Lodge Centre
to treat 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 advise us if you change your name or address while this declaration is in force.
You can cancel the declaration
at any time by notifying White Lodge Centre – it will not then
apply to donations you make on or after the date of cancellation or such date
as you specify.
| Full Name: (block capitals): | |
| Signature: | Date: |
| Office use only | Ref no: | Processed: |
White Lodge Centre. A company limited by guarantee. Registered charity no 286238.