Stanley Grange Community Association

Membership Form 2016/17

This is a: New membership application Renewal * *Membership No:

PERSONAL DETAILS

Title Surname

Forenames Date of Birth

ADDRESS

House No/Name Phone (Home)

Street Phone (Mobile)
Town/City
Post Code Country

e-mail address
* Please provide an e-mail address, as this is the cheapest way for SGCA to communicate with its members.

Signed Date

For members under 18: Parent or Guardian Name (block capital): …………………………………
Signed Date

What skills do you have,

that could be useful to the
group?

Type of membership applied for. Please tick one option below:

 Affiliate member: Free. You will be included in all of the SGCA email distribution lists, invited to all
AGMs and general meetings and consultations on future developments at Stanley Grange. This
membership option does not enable you to vote on SGCA matters, nor stand as a trustee.
 Full member: £1. In addition to the ‘affiliate member’ benefits, full members are able to vote at AGMs
and general meetings, as well as stand for election as trustees.

Donations are gratefully accepted. Please circle: £20 £50 £150 £250 £500

Send the completed form, with a cheque made payable to “SGCA” to

Sarah Coulson, Charity Manager, SGCA, Stanley Grange, Roach Road, Samlesbury, PR5 0RB
Payments can be made directly to:
Stanley Grange Community Assoc.
Acc No: 10888190 Sort Code: 16-14-32 (Royal Bank of Scotland)
Please include full details of your online payment with this application.

Please take the time to complete the Gift Aid declaration overleaf; this enables us to get even more
money out of all past and future donations…
Gift Aid Declaration:
Name of Charity: Stanley Grange Community Association

Please treat

 The enclosed gift of £ as a Gift Aid donation; OR

 All gifts of money that I make today and in the future as Gift Aid donations; OR

 All gifts of money that I have made since 25th November 2010 and all future gifts of money that I
make from the date of this declaration as Gift Aid donations.

 Please tick the appropriate box

You must pay an amount of Income Tax and/or Capital Gains Tax for each tax year (6 April one year to 5
April the next) that is at least equal to the amount of tax that SGCA will reclaim on your gifts for that tax year.

Name: .........................................................................................................................................
Male/Female: ..............................................................................................................................
Age: .............................................................................................................................................
Date of Birth: ...............................................................................................................................
Address: ......................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Postcode: ....................................................................................................................................

Please notify the charity or if you:

1. Want to cancel this declaration.
2. Change your name or home address.
3. No longer pay sufficient tax on your income and/or capital gains.

Tax claimed by the charity

• The charity will reclaim 25p of tax on every £1 you give on..

If you pay income tax at the higher rate, you must include all your Gift Aid donations on your Self
Assessment tax return if you want to receive the additional tax relief due to you.