First name

Last name

Home phone number

Mobile phone number

Preferred contact number

HomeMobile

Postcode

Address line 1

Address line 2

Town / City

County

Occupation

Date of birth

Proposed Supporter Group details

Proposed name of the Supporter Group

Your funding

Please tick the following statements to show you have read and understood them:

The first £10,000 you raise will be spent on our charitable objectives - funding research/providing information & support/raising awareness and influencing policy.Once you've raised over £10,000, you'll be able to nominate the money to be designated to one specific area of our work.100% of the funds you raise go to furthering our goals and your designated area of funding; we do not use funds raised by Supporter Groups to cover general office or fundraising costs.

Please select where you would like your funds to be designated when you have raised over £10,000:

Collaborative Research programmesHigh grade brain tumour researchPaediatric brain tumour researchThe HeadSmart campaignPlease use my funds for the charitable objectives that are most needed as determined by the Trustees and the CEO

Your responsibilities

Please tick the following statements to show that you will act in accordance with your responsibilities when running a Supporter Group:

I will use the full Charity name, The Brain Tumour Charity and Registered Charity number 1150054 (England and Wales) and SC045081 (Scotland) on all publicity and documents relevant to my Supporter Group.I will not act in any way to bring The Brain Tumour Charity into disrepute.I will remain in close contact with The Brain Tumour Charity and respond to requests for information from The Charity when required.I will act in accordance with the relevant legislation and guidance on fundraising (further information and advice will be provided with The Supporter Groups' Toolkit).I will ensure that there is always a primary contact available for The Charity to get in touch with regarding my Supporter Group.I should not seek to set up a Supporter Group bank account in the name of The Brain Tumour Charity.I also understand that these terms and conditions may be varied from time to time and that I will be notified in writing of such changes.

Your details

Proposed Supporter Group details

Your funding

Your responsibilities