Name:  

Address:

 
Postcode:   Telephone:  
  Fax:  
Email:  
   
Date:  
 
Please indicate level of injury if applicable:  

New Membership: £3.00
Renewal: £3.00
(First year FREE if spinal cord injured)

 

 

 
Donation: £
 

*I would like this donation to be treated as Gift Aid
*I would like all the donations I make to INSPIRE be treated as Gift Aid
*I would like the donation I made on ..../..../.... to be treated as Gift Aid
*I would like all the donations I have made since 6 April 2000 and all donations I make from the date of this declaration until I notify you otherwise to be treated as Gift Aid

*Please see notes on Gift Aid Declaration

Signature ________________________ Date ____ /____ /____

 

Please make cheque/PO payable to INSPIRE

Please print off, complete and send to

The INSPIRE Foundation
Spinal Treatment Centre
Salisbury District Hospital
SALISBURY
SP2 8BJ

Tel: 01722 336262 extension 2465

Registered Charity: 29628