Application to join Poole Heart Support Group

PLEASE PRINT THIS PAGE, then hit the back arrow above, to return to the PHSG web site.

I wish to become a member of Poole Heart Support Group and enclose
my first subscription of £8 (if joining between 1st Jun and 31st Dec)
or £4 (if joining between 1st Jan and 31st May).


I understand that future annual subscriptions will be due on 1st June.


Full Name (Mr/Mrs/Miss/Ms) (Please print) ______________________________

________________________________________________________________________


Address ________________________________________________________________

________________________________________________________________________


Postcode _____________________


Telephone _______________________


Email address (Please print) ___________________________________________

My subscription is   £ _____

Optional donation    £ _____

Calendar (£3)        £ _____

Walking book (£3)    £ _____


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Total         £ 
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Where did you hear about us ____________________________________________


Please send the completed form, together with your cheque, to:-

PHSG Head Office
Poole Community Health Centre
Shaftesbury Road
Poole
Dorset
BH15 2NT

Telephone
01202 683363                         

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Office use only

Membership number ________   Treasurer __________ Database _____________