Membership Application Form
Please print, complete and send to
The Miscarriage Association
c/o Clayton Hospital
Northgate, Wakefield
West Yorkshire WF1 3JS

* delete where applicable

I/We* would like to join The Miscarriage Association1
Name: .................................................................
Address: .............................................................
...........................................................................
County: ...............................................................
Postcode: ...........................................................
Telephone: ..........................................................
E-mail address: ...................................................

I/We* enclose a cheque/postal order for £ ......... (UK Sterling only) for membership fees for one year
OR
I/We wish to pay our membership fee by Visa/ Access/ Mastercard*:
Card No: ............................................................
Expiry Date: ....................... Issue no.: ..........

Fees:
Individual/couple (UK) £20
Individual/couple (UK), unwaged/ on benefit £5
Individual/couple (outside the UK)) £25
M.A. Support Group (registration only) Free with branch agreement
M.A. Support Group (1-5 newsletters) £22.50 with branch agreement
Independent organisations & support groups £30

Cheques and postal orders should be crossed a/c payee only and made payable to The Miscarriage Association

I would like to pay my membership fee by banker's order.
(Tick if applicable)

Gift AidGift Aid - making your money go further
If you are a U.K. taxpayer, you can increase the value of your membership subscription to The Miscarriage Association at no cost to yourself by ticking the Gift Aid box below. You must pay an amount of income or capital gains tax at least equal to the tax we reclaim on your membership fee (up to 28%).

I would like my membership fee and any donation I make after 8 April 2000 to be considered as a Gift Aid donation.
(Tick if applicable)

1The Miscarriage Association is a registered charity and a company limited by guarantee. Should the company be wound up, I promise to pay the sum of £1 towards its debts if asked to do so.