LEEDS MENCAP ASSOCIATE MEMBERSHIP FORM
Leeds Mencap requires everyone who uses a Leeds Mencap service to become an Associate Member. If multiple people in a
family use Leeds Mencap’s services, only one person in the family needs to become an Associate Member. It costs £1 to
become an Associate Member for one year. Simply complete the form below and return it with your payment to Leeds Mencap,
Londesboro Terrace, Leeds, LS9 9NE. Membership is renewable on an annual basis - we will remind you one month before
your membership expiry date.
ASSOCIATE MEMBERSHIP FORM
Name(s): (Mr/Mrs/Ms) …………………………………………………………………………………………….…….
Individuals who use the service (if different from above)………………………………………………………….
Home Address: ………………………………………………………………………………………………………...…
……………………………………………………………...………………………Post Code ………………………….
Tel No. ……….…………………………………………. Email address:………….…………………………………
Please tell us which Leeds Mencap services you use:
Hawthorn Family Support Centre
Youth Club
Me2
Playschemes
Gateway
Rookery
Friday Club
Family Support Group
I/We enclose my/our annual subscription of £1
I/We enclose an additional donation of: £ ……………...
Total amount: £ ……………...
If you are renewing your membership and know your membership number please quote it here ..………………
Signed: ……………………………………………. Date: ……………………………
We will use your contact details to send you details of services and benefits that may of interest to you and information on Leeds
Mencap’s activity. In order to make our mailings more efficient and to ensure they are relevant to you please indicate which
areas you would like to receive information about:
Information on Leeds Mencap and our services
Information on other learning disability services
Leeds Mencap’s Newsletter
If you would NOT like to receive any communications please tick here
GIFT AID DECLARATION
If you are a tax payer we can claim back the tax already paid on your income for the above from the Inland Revenue. Gift aid
will increase a £12 subscription to £15 automatically at no cost to you! Simply fill in the below declaration:
DECLARATION: I would like Leeds Mencap to treat:

the enclosed donation/subscription of £………. which I made on ……/……/…..(date)

and all donations I make from the date of this declaration until I notify you otherwise as Gift Aid Donations.
Signature:………………………………………………………………
1.
2.
3.
4.
5.
6.
Date ….../……./……….
You can cancel this declaration at any time notifying Leeds Mencap.
You must pay an amount of income tax and/or capital gains tax at least equal to the tax we reclaim on your donations in the tax year.
If in future your circumstances change and you no longer pay tax on your income and capital gains equal to the tax that we reclaim,
you can cancel your declaration (see note1).
If you pay tax at the higher rate you can claim further tax relief in your Self Assessment tax return.
If you are unsure whether your donations qualify for Gift Aid tax relief, ask Leeds Mencap or ask your local tax office for leaflet IR113
Gift Aid.
Please notify us if you change your name and address.
Registered Charity Number: 1091809
Registered Offices: Leeds Mencap, Londesboro Terrace, East End Park, Leeds, LS9 9NE
Tel: 0113 235 1331 Email: info@leedsmencap.org.uk Web: www.leedsmencap.org.uk