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Help stop the suffering of children caused by disease and disability

Sponsorship form

Did you know - If you are a UK tax payer we

Challenge events

can claim tax back on your donation.

We who have given our names and addresses below, and who have ticked the box entitled Gift Aid want Action Medical Research to reclaim tax on the donation detailed below, given on the date shown. We understand that each of us must pay income tax or capital gains tax equal to the tax reclaimed by the charity on the donation.

Participant’s name Event

Date

SPINATHON - ACTION MEDICAL RESEARCH

07/05/2011

Address Postcode Full name

House number

Postcode

Amount Amount Date given pledged given (dd/mm/yy)

Sub total £ If you run out of room for names don’t worry, photocopies of this side of the form will be accepted

Please help us to fund the next medical breakthrough for children Action Medical Research registered office: Vincent House, Horsham, West Sussex RH12 2DP T 01403 210406 F 01403 210541 E info@action.org.uk www.action.org.uk

Paying in slip No.

Gift Aid 3


Full name

House number

Postcode

Amount Amount Date given pledged given (dd/mm/yy)

Paying in slip No.

Gift Aid 3

Total amount raised ÂŁ Please return this form to:

Office use only:

Action Medical Research Challenge events Vincent House Horsham West Sussex RH12 2DP

Amount received

ÂŁ ........................

Date banked

..........................

Paying-in slip ref.

..........................

Please make cheques payable to Action Medical Research


Spinathon Sponsor Form