
				Chesterfield & North Derbyshire Tinnitus Support Group

HELP AND SUPPORT FOR PEOPLE WITH TINNITUS

CHESTERFIELD & NORTH DERBYSHIRE TINNITUS SUPPORT GROUP

Affiliated to the British Tinnitus Association

(Registered Charity No. 1011145)

MEMBERSHIP FORM

Print Membership Form

All personal details will be maintained on a database and will not be passed to any individual/organisation without your permission

Application Details

PLEASE PRINT CLEARLY

Surname

First/Forename(s)

Address

Post Code

Telephone Number

E-mail Address

The following information is requested as part of the group’s monitoring process and is given on a voluntary basis

Age Group

Under 20

20 - 35

35 - 50

51 - 64

65 and over

Please Tick

PLEASE COMPLETE THE FOLLOWING INFORMATION

Membership/Donation

Cost of Membership

Please complete

Benefits of Joining

Membership of Tinnitus Support Group

£5.00

Membership includes 10 Monthly Newsletters, 9 Monthly Meetings, Access to Helpline Support

Donation

We would be grateful for any donation you can make to help continue our work

Membership of the British Tinnitus Association (BTA)

£10.00

Membership includes 4 BTA Quarterly Journals

[Membership is Optional]

Total Enclosed

A couple living at the same address and receiving one copy of each Newsletter will be covered by a single subscription. If paying by cheque please make payable to:-

CHESTERFIELD TINNITUS SUPPORT GROUP

Please return to: Chesterfield & North Derbyshire Tinnitus Support Group, 70 Saltergate, Chesterfield, S40 1JR