Burnham on Crouch u3a

Membership Application Form

I apply to become a member of Burnham on Crouch u3a.

Fields marked * are required.

Personal details

Title

First name *

Surname *

Address

Address line 1 *

Address line 2

Town *

County

Postcode *

Contact details

Telephone (home)

Telephone (mobile)

Please provide at least one telephone number.

Email address *

Confirm email address *

To keep our costs down, we communicate by email where possible.

Membership fee

£15.00 (full year membership) Membership year runs 1st June to 31st May. The full year rate applies for applications received from 1st June.

Payment method

Bank transfer (BACS) — preferred
Burnham on Crouch University of the Third Age (u3a) | Sort code: 20-19-95 | Account: 40950181
Please use your surname and initial as the payment reference.

Cash at a meeting

Gift Aid

Gift Aid Declaration

I am a UK taxpayer. I understand that if I pay less Income Tax and/or Capital Gains Tax in the current tax year than the amount of Gift Aid claimed on all my donations, it is my responsibility to pay any difference. I want to Gift Aid my membership subscription to Burnham on Crouch u3a. The membership subscription fee is £15.00 and Gift Aid will be claimed on this amount if I agree above. This fee secures membership of the u3a only and does not secure rights to personal use of any facilities or services provided by the u3a. This fee also includes a £4 fee that is paid to the Third Age Trust, the national organisation that supports u3as in the UK. The Trust provides a wide range of services and benefits, including liability insurance cover.

I am a UK taxpayer and I want to Gift Aid my membership subscription to Burnham on Crouch u3a.

Emergency contact

In case of emergency while you are involved in u3a activities, who should we contact?

Name *

Relationship

Best telephone number *

Medical information

Do you have any medical conditions or needs that we should know about in case of emergency while you are involved in u3a activities? This information is held in strict confidence and will only be used in case of emergency.

Groups and activities

Please tick any groups or activities you are interested in joining.

Are there any other activities or interests you would like to see as a future group?

Would you be willing to consider leading such a group, with help and advice from the committee?

Yes

Possibly

Terms and Conditions of Membership

I understand that all u3a activities are undertaken at my own risk, and I agree to:

Abide by the principles of the u3a movement
Always act in the best interests of the u3a and never do anything to bring the u3a into disrepute
Abide by the Burnham on Crouch u3a constitution
Treat fellow members with respect and courtesy at all times
Comply with and support the decisions of the elected committee
Advise the committee of any change in your personal details as recorded on this form

I confirm I have read and agree to the Terms and Conditions of Membership of Burnham on Crouch u3a. *

Privacy statement: Your personal details will be held securely and will be used solely for the purpose of administration and distribution of Burnham on Crouch u3a communications. We will communicate with you by email where possible.