Application for Full membership
This application is for Adults or Children that are
receiving treatment. If you are not receiving one of the treatments described
in the form below, there is an Associate
membership form available here.
Please print out the form, complete ALL
sections CLEARLY and in BLOCK CAPITALS and then post it to us with any
donations to:
PINNT Membership Scretary, 58 Knockhall Road, Greenhithe, Kent. DA9
9HF
I wish to apply for Full Membership of PINNT
| Mr/Mrs/Miss/Master/other: |
| First name(s) |
| Surname |
| Company name |
| Address |
| |
| |
| |
|
Post code |
| Tel
No: |
Mobile |
| Email
address |
Type
of treatment: (Please tick those applicable)
|
|
Intravenous |
|
Naso-Gastric |
|
Gastrostomy |
|
Jejunostomy |
|
| Date
of birth: |
| Date
nutrition therapy commenced: |
Hospital(s)
attended for your artifical nutrition therapy:
|
| Name
of consultant: |
Condition
necessitating treatment: |
Would
you be willing to act as a contact for fellow PINNT members:
|
Full Membership of PINNT is only £5
| DONATIONS ARE ALSO GRATEFULLY
RECEIVED |
| I would
like to make a donation of £ |
|
|
Please tick here if you require a receipt |
|
Gift Aid Declaration:
I am a UK taxpayer and declare that I would like PINNT to reclaim
the tax on the following donations(s):- |
| This donation of £ |
|
|
Please tick here if you would like PINNT to reclaim the tax
on all future donations I make until further notice. |
|
1. You must pay an amount of income tax and/or
Capital Gains tax at least equal to the tax that PINNT reclaims
on your donations in the current tax year (currently 28p for each £1
you donate).
2. You can cancel this Declaration at any time by notifying PINNT.
3. In the future your circumstances change and you no longer pay
tax on your income and/or capital gains tax eqaual to the tax that
PINNT reclaims you must cancel your declaration (see note 1)
4. If you are unsure whether your donations qaulify for Gift Aid
tax relief, ask PINNT.
5. Please notify PINNT if you change your name of address. |
Signature
|
|
Date /
/ (dd/mm/yy)
|
| If signing on behalf of a child (parent/guardain)
please print your name: |
| |
The Data Protection Act of 1984 requires that
we bring your attention to the fact that information declared on this
form will be held on a computer and will be used as part of the PINNT
membership and mailing list.
If you would like to find out more about gift aid
please see the 'ways to give section' |