Please print this form and send to:­

CLACTON & DISTRICT STROKE ASSOCIATION
85 FRINTON ROAD
HOLLAND ON SEA
ESSEX
C015 5UH
TELEPHONE: 01255 815905
FAX: 01255 815905
Registered Charity Number 1054049
 

I enclose a donation of £__________
Full Name:      __________________________________
Address:         __________________________________
                      __________________________________
                      __________________________________
                      __________________________________
Post Code:      _____/_____/_____(this must be included)
Date:              ________________
Signature:      __________________________________
 

Thank you for your support.