North London ME Network

charity no 1117882

MEMBERSHIP FORM: NEW MEMBER

Subscription rate: £7 per year. Please note that in the year you first join your subscription runs until the end of December of that year, regardless of which month you join. From then on renewal is due each January. New members joining July-December pay £3.50 for the remainder of the year.

Cheques should be made payable to the North London M.E. Network and
should be sent with this form to NLME Network Secretary, 48 Wardell Close, Mill Hill, London, NW7 2LG

Please print clearly in capital letters.

DATE ……………………………………………………………………...
NAME ……………………………………………………………………...
ADDRESS ……………………………………………………………………...
……………………………………………………………………...
……………………………………………………………………...
POSTCODE ……………………………………………………………………...
PHONE NO ……………………………………………………………………...
EMAIL ……………………………………………………………………...

Membership fee ..........
Voluntary donation ..........
Total amount enclosed .......…

How did you hear about us?

Please circle one or more of the following
  1. Word of Mouth
  2. Action for ME
  3. AfME Interaction magazine
  4. ME Association
  5. Poster in library
  6. Poster in GP surgery/hospital
  7. Green Events Listing
  8. Network ME (Edmonton)
  9. Other (please specify)

Events and Socials

When arranging events it’s useful for us to know what time of day is best for people – please circle one or more of the following

10 1pm 1 4pm 4 7pm 7 10pm

Help needed

As we are all ill there's always a need for assistance with work. Here are the main areas it is currently needed; please circle one or more of the following if you think you might be able to help out. (This will not commit you to anything, but will just mean we might contact you later with more information.)

  1. General help on committee (meetings currently every 4-6wks in Tottenham)
  2. Stuffing envelopes for mail-outs (currently every 3months, off Holloway Rd)
  3. Offering your home for Network events (perhaps 10-20 people -occasional)
  4. Being a ‘computer buddy’ (doing small computer-related tasks for a non-computer user)
  5. Stewarding at events (e.g. welcoming people at door, making sound recording, taking photos etc - occasional)
  6. Other offer:

 

Suggestions

Any suggestions you would like to make about what the Network does or about activities you would be interested in. (Please bear in mind that your suggestions may need some input from you to materialise!)

 

 

 

Details for the members' contact list (optional)

Your name, address, phone no and email and any details provided below will be included. Membership of the contact list is optional but only members who opt in will receive the list themselves.

Would you like to join the contact list? (please circle) YES / NO
Your interests .....................................................................................................
…………………………………………………………………………………………..
Age (please circle): 18-25 25-30 30-40 40-50 50-60 60-70 70 plus
How ill? .........................................................................................................…..
Times it is convenient to be called .....................................................................
Kinds of contact you would like (e.g. other young people, other severely ill people, people with positive outlook, etc) ………………………………………… ………………………………………………………………………………………….

Ethnicity information

The organisations which fund us require, as a condition of funding, the following information on members’ ethnicity. We would be most grateful if you could help by completing this form. This information will not be made public, it is for funders only. Thank you.

Please tick

WHITE

British

 

Irish

Turkish/Turkish Cypriot

Greek/Greek Cypriot

Kurdish

Any other white background

MIXED

White and Black Caribbean

White and Black African

White and Asian

Any other Mixed background

ASIAN OR ASIAN BRITISH

Indian

Pakistani

Bangladeshi

Any other Asian background

BLACK OR BLACK BRITISH

Caribbean

African

Somali

Eritrean

Nigerian

Ghanaian

Any other African background

Any other Black background

CHINESE OR OTHER ETHNIC GROUP

Chinese

Filipino

Vietnamese

Any other ethnic group

Gift Aid

Now that the North London ME Network is a charity, using Gift Aid means that for every pound you give, we will receive an extra 28 pence from the Inland Revenue, helping your donation go further. This is true both for ‘donations’ and for the subscription fee. Thus a £10 donation would actually be worth £12.80 to us.

Please note! You must be a payer of either income tax or capital gains tax to be eligible for Gift Aid. If you are not a tax payer (be it tax on capital gains, interest in a bank account, a pension or any other form of income or capital gains tax) then please do NOT fill in this form, otherwise you may be liable to pay money back to the Inland Revenue. However you could get a partner of friend who is a tax payer to make the donation then we will be able to apply for Gift Aid from their donation instead.

Gift Aid does not cost you a thing.

I would like to make a donation to the North London M.E. Network using Gift Aid. My details are:

First name Surname


Address

Postcode

I would like to Gift Aid the enclosed subscription/donation of £________________

I would like to Gift Aid all future subscriptions and donations I make to the North London ME Network until I notify you otherwise.

Signed _________________________________________________________

Date __________________________________________________________

To qualify for Gift Aid, what you pay in income tax or capital gains tax must at least equal the amount the charity will claim in the tax year. If you are not a tax payer then you may be liable for any ‘gift aid’ claimed by the charity from the Inland Revenue.