Membership Application - Burnham on Crouch

u3a membership runs from 1st June to 31st May each year. If you are joining between 1st June and 1st December, the subscription is £15. If you are joining between 1st December and 31st May, the subscription is £9. Please complete and submit this form AND pay your membership fee by Bank Transfer, Cash, or Cheque (details will be given after you click 'Submit').

u3a Membership Application

Name

First Name

Last Name

Address Line 1

Address Line 2

Town

PostCode

Phone (Home)

Phone (Mobile)

Gift Aid Status

Would Like to Register for Gift Aid * A form will be sent to you

Do not want to register for Gift Aid

Emergency Contact

First Name

Last Name

Relationship

Best Telephone Contact Number

Do you have any medical conditions or needs that we need to know about in case of emergency while you are involved in u3a activities? Please tell us below

Please list below any interest groups you may be interested in joining or starting.

Payment Method - Please Let Us Know How You Will Pay

Bank Transfer - £15

Cheque - £15

Cash - £15

If you are human, leave this field blank.

PRIVACY STATEMENT: Your personal details will be held securely and will be used solely for the purpose of administration and distribution of u3a communications.

Please pay your renewal fee by bank transfer if you can. Details will be shown when you submit the form and will also be emailed to you.