Member Payment details

Member Payment details

Dementia Active Charity (no: 1195246)
Members Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of person completing this form

First NameLast Name
Email
example@example.com
Which Centre do you attend?

Banbury CentreChipping Norton CentreCarterton CentreFreeland Village Hall
What type of transport do you require?

One way transportBoth way transportWheelchair transport (General sessions only)No transport required
What type of session are you attending?

General sessionFour seasons club (Banbury and Chipping Norton only)
Your Suggested Donation is:-
Suggested donation per session, which if required does include transport by minibus or volunteer driver, if available. (By ticking a box below, I confirm this payment is a voluntary donation and not a compulsory payment for attending a group. I understand this can be changed at any time).*

I will pay the suggested donationI'm sorry I can't donate at this time£15£25£50Other
Gift Aid is reclaimed by the charity from the tax you pay for the current tax year. Your address is needed to identify you as a current UK taxpayer. In order to Gift Aid your donation you must tick the box below:*

I want to Gift Aid my donation to Dementia Active (Charity no. 1195246). I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax in the current tax year than the amount of Gift Aid claimed on all my donations it is my responsibility to pay any difference.I am not able to Gift Aid at this time.
There is a separate charge of £2.50 + VAT for your meal per session, which is collected monthly.

(VAT No. 410 8071 37, you can request a VAT receipt by going to the home page of our website).

Each week your donation will be requested from your bank. The suggested donation is calculated per annum and is based on our Charity's outgoings. It allows for bank holidays and the christmas closure. Online payments are intended for 'occassional blocks' of sessions and does not include bank holidays or the christmas closure.

The meal charge will be requested separately from your donation.

We will request the donation from your bank each week, while you remain a member unless you ask us not to.

If your donation is collected in error, or you feel it is unafordable please contact us.
Direct Debit and GoCardless
GoCardless is the UK’s leading Direct Debit provider and is used by over 2,000 organisations. GoCardless is sponsored by RBS and is authorised by the FCA.

Switching to Direct Debit with GoCardless will save you the hassle of paying each week. You’ll be notified of any upcoming payments, and you can cancel them whenever you want.(See cancellations charges, click here). What’s more, the Direct Debit Guarantee makes this the safest way to pay.

Please contact Dementia Active if you are unable to pay via Direct Debit.

Account Name*
Sort Code*
Account No.*
Are you authorised to set up this direct debit?*

YesNo

We look forward to welcoming you to one of our groups.
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