APPLICATION FOR MEMBERSHIP |
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| Contact Name: | |||
| Address: | |||
| Telephone No: | |||
| Mobile No: | |||
| Email: | |||
| If JOINING AS A HOUSEHOLD MEMBERSHIP Please fill in the relevant information below of all family members: - | Name: | Age if under 16 | |
| Name: | Age if under 16 | ||
| Name: | Age if under 16 | ||
| Name: | Age if under 16 | ||
| Name: | Age if under 16 | ||
| MEMBERSHIP TYPE | |||
 | Household Membership | £ 20.00 | |
| Individual Membership | £ 15.00 | ||
Household Membership covers all living at one single address.
Children under 16 MUST have parental/Guardian consent and can join under a
Household Membership ONLY
Please send the completed form, together with a cheque made payable to Ages-AHA to:
33, Rochester Way, Basildon, Essex SS14 3QG.