TAKE HEART
LIFE MEMBERSHIP FORM

Please print this sheet, complete the details and send to

Mr George Harrison
Take Heart
The Yorkshire Heart Centre
F Floor
Jubilee Building
LGI
LEEDS
LS1 3EX
____________________________

Life Membership fee - £1.50 each
Badges - £1.00 each
Life membership is open to everyone

Title (delete as appropriate) Mr & Mrs/Mr/Mrs/Miss/Ms

Forename:

Surname:
Address

Postcode:

Telephone:

I have also enclosed badge fee of £2.00/£1.00 (delete as app)

PLEASE MAKE CHEQUES PAYABLE TO TAKE HEART