Afasic Membership form

I would like to become a member of Afasic.


Name: Mr/Mrs/Ms....................................................................................................

Address..................................................................................................................

...........................................................................Post code ...................................

Telephone No  ...................................... E-mail .....................................................


I would like to join under the following category (please tick one):

	Family £15		Student £5
	Professional £20		Person on Benefit £5
	Institutional £35 (to receive three copies of all mailings		Retired £5
	Young Person £5 (aged 16-30 with a communication impairment		Overseas £25 (within Europe)
	Overseas £30 (worldwide)

For Institutions - Contact Name:

For Parents - Name & date of birth of children with a speech & language impairment:

The best way to pay is by standing order. This ensures that you don't miss out on newsletters and helps us by keeping our administration costs down.

1. I am enclosing a cheque:

	I enclose my Subscription	£ ________
	Plus my donation to Afasic	£ ________
	Total	£ ________

2. Or Debit my credit card (Visa/Mastercard/American Express)*
for £ _________

Card Number _______________________________________

Expiry date ____/____ Signature _______________________ Date ______________

* Please delete as appropriate

3. Or I have completed the standing order form which is enclosed (see link below)

Don't forget, if you are a tax payer then we can maximise your payment by claiming back the tax from the government. Just complete the "Gift Aid Declaration" below and send it off to us with the membership form, we will do the rest. It won't cost you a penny.

Standing Order form

Gift Aid Declaration form


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FREEPOST RRUK-JSAT-CUGS, AFASIC, Olive House 1st Floor, 20 Bowling Green Lane, LONDON, EC1R 0BD