Membership and/or Donation Form

To Janice Hedge, Membership Secretary, MDG, 26 Emanuel Avenue, Acton, London W3 6JJ

I/We wish to apply for Individual/Household/Group membership as indicated below:

Individual:	£10:00 per year	……
Joint household/family:	£15:00 per year	……
Group (Offices, Clubs etc.):	£15:00 per year	……

I/We wish to make a donation of: £……………………

Gift Aid declaration
(Please sign this declaration whether you are applying for membership or making a donation, as this will allow us to receive extra money by claiming back the tax you have already paid on the amount you are giving.)

I am / We are a tax payer in the United Kingdom relative to amounts donated and would like the charity to treat all donations I make from the date of this declaration until I notify you otherwise as Gift Aid donations. I am over 18