To send this form to us right now, simply complete the form below and click on "Send".
To print out this form click on the print button at the top-right or click the "Print" button at the bottom.
To download the form to fill out later, click on the PDF button at the top-right, this will allow you to download the form in PDF format to print later.

YES, I would love to contribute to the work undertaken by your Association and will support you in the following way:

	A single donation of	R
	A monthly donation of	R
	(please send me the necessary debit order forms)

Family Membership:
Parents & Children		R 100 Annual
Senior Citizens		R 50 Annual
		R 1,000 Life Membership
Corparate Membership:		R 1,000 Renewal
		R 5,000 Life Membership

Alternatively, you can make a direct deposit into our bank account:

	I would like to make a direct deposit. (if you choose this option, please fax us a copy of your deposit slip and personal details so we may thank you for your kindness)
Account Name :	KZN Cerebral Palsy Association
Bank :	First National Bank
Account Type :	Current Account
Account Number :	508 11 33 0451
Branch Name :	Crompton Street, Pinetown
Branch Code :	22 16 26

If you want to make a donation by cheque, simply print out this form fill it in and post it with your cheque to us.

You will see our postal address on the right-hand side of this page or on our contact us page.

personal details

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First Name(s) :
Surname :
Work Phone :
Home Phone :
Cell Phone :
Email Address :
ID Number :
Address :
Postal Code :
Please collect my donation :	(if you are in the greater Durban area, we shall collect from you during office hours, please provide your physical address)

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