Please print out this form, fill it in and return to:

Winchester Youth Counselling, Jubilee House, 1-3 Swan Lane, Winchester, SO23 7AA.

Donation Form

First Name:

Surname:

Address:

Postcode:

Telephone:

Email:

Please tick / select as appropriate:

I would like to donate £50 ____ £25 ____ £10 ____ Other £ ___________

I enclose my cheque or postal order, made payable to Winchester Youth Counselling.

PLEASE GIFT AID YOUR DONATION

I confirm that I am a taxpayer and authorise Winchester Youth Counselling to recover Income Tax and the Standard Rate on all my recorded gifts to its funds from 6th April 2003 until this authority is cancelled in writing.

Surname:

Other Names:

Title:

Address:

Post Code:

Telephone No.:

Signature ________________________________________________________

Date ___/___/_____

Data Protection

Winchester Youth Counselling will use your personal information to provide you with the services, products or information you have requested, for administration purposes and to further our charitable aims.

We would like to keep you informed of our important work. Please tick this box if you would prefer not to receive information about the future activities of Winchester Youth Counselling.