PlusCarer Pass Form

Email*

Email address used for administration of the pass

Phone*

Phone number used for administration purposes

First name of passholder*

The person who requires additional support

Surname of the passholder*

Name of the person administering the pass

Complete this only if you are applying on behalf of someone

Address*

Town*

Post Code*

Renewing Pass

Please provide exisitng membership number

Declaration*

I, (or the disabled person who I represent), qualify for issue of a Plus-Carer Pass according to the criteria set out in the website.

GIFT AID DECLARATION - I am a UK taxpayer and wish Almond Valley to reclaim the tax on this transaction.

Simply TICK THE BOX, and every £1 of this transaction could be worth £1.25 to our charity

Please tick this box if you'd like to receive further communications (email and/or post) from Almond Valley Heritage Trust.

Apply for an annual Plus Carer Pass