Anxiety UK,
Zion CRC, 339 Stretford Road,
Hulme, Manchester. M15 4ZY

Tel/Fax: 08444 775 774
Tel: 0161 227 9898
Fax: 0161 226 7727

Reg Charity No: 1113403
Company Reg No: 5551121

Joining ANXIETY UK online

Please read this first - Instructions for joining online.

Fill out the following application form
Our online card payments are processed by WorldPay.
Once your payment has been processed by WorldPay, we will then send your Membership Pack.
Your support is VERY much appreciated. Thank you.

You can also join ANXIETY UK over the phone (with a credit/debit card) by calling 08444 775 774 or by printing off an application form (requires Acrobat Reader).

Please note that credit/debit card payments incur a 5% surcharge to cover overhead costs (included in prices below).

Please note that online payments take 2 to 3 working days to clear . Once your payment has cleared we will send out your membership pack

Online membership application form

All fields marked with a * are required

Personal Details

* Title:

* First name:

* Surname:

* Address

* Postcode

* Telephone no:

* Date of Birth (dd/mm/yyyy):

* Email address:

* Confirm email address:

Membership types

Although the amounts stated below (inclusive of 5% card surcharge) are the minimum for membership we welcome any donations you can give.

Individual membership - One year
UK & Northern Ireland - £22.05
Europe - £26.25
International (non European) - £31.50
Individual membership - Three years
UK & Northern Ireland - £52.50
Europe - £63
International (non European) - £78.75

Professional membership - individual - one year
UK & Northern Ireland - £31.50
Europe - £36.75
International (non European) - £42
Professional membership - individual - three years
UK & Northern Ireland - £78.75
Europe - £94.50
International (non European) - £110.25

Professional membership - organisation - one year
UK & Northern Ireland - £52.50
Europe - £57.75
International (non European) - £63
Professional membership - organisation - three years
UK & Northern Ireland - £131.25
Europe - £147
International (non European) - £162.75

If you are able to give an additional donation, this would be very much appreciated.

Is this a membership renewal? Yes No

Anxiety conditions(not applicable to professional members)

Details of anxiety condition(s) you are suffering from/working with/interested in: (please check all appropriate boxes).

Where did you hear about ANXIETY UK?

Monitoring Information To ensure the service we provide is catering for all groups in society, please indicate your ethnic background:

Contacts list (not applicable for professional members) ANXIETY UK publishes contacts lists in its newsletters for individual members only, to enable members to make contact with others living with similar difficulties. If you would like to be included in ANXIETY UK contacts lists, please write about 50 words below:

Example text:

Sally Smith, aged 29, 4 Any Street, Anytown, AT3 9TA, Tel: Suffers from social phobia. Would like to hear from other members, either locally or otherwise for friendship and support.

Media Work (not applicable for professional members)

At ANXIETY UK we play an active role in educating the general public about anxiety disorders in an attempt to bring about de-stigmatisation. We do this by working closely with the media. If you would like to be involved, please complete the following section (you must be contactable by phone and be happy for journalists etc. to contact you directly).

Name:

Age:

Area of Residence:

Telephone no (essential):

Brief details of anxiety condition:

Which are you happy to take part in:
Television appearances
Radio interviews
Magazine/newspaper interviews

Are you able to travel? Yes No

Contact Preferences

Would you like to be contacted by an ANXIETY UK representative to discuss your needs and the services that ANXIETY UK can provide? (We will call you back Mon - Fri 9.30am to 4.30pm)

Yes please contact me on the telephone landline number below

Please note: unfortunately due to limited resources, we are unable to call mobile telephone numbers

Telephone landline no:

Is it okay for our ANXIETY UK representative to leave a message on your answering machine or the person who answers your phone?

Yes please leave a message

Gift Aid

If you are a UK taxpayer, you can increase the value of your purchase to ANXIETY UK by almost a third. Check the following box if you are eligible for Gift Aid. Under the terms and conditions of the Gift Aid Scheme, you are entitled to cancel your declaration within 30 days from the date of making the declaration. You may do so by notifying ANXIETY UK by any form of communication. A record of the cancellation of your declaration, including the date of your notification to cancel will be kept by ANXIETY UK. If you pay tax at the higher rate you can claim further tax relief in your Self-Assessment tax return. If you are unsure whether your donations qualify for Gift Aid tax relief ask your local tax office for leaflet 1R113 Gift Aid. Please notify ANXIETY UK if you change your name and address.

Gift Aid Declaration Please treat all donations made by me since 1 Dec 2001 as Gift Aid Donations. I understand I must have paid an amount of income tax or capital gains tax equal to the tax you reclaim on my donations

Agoraphobia Social Phobia Generalised Anxiety Disorder Body Dysmorphic Disorder Irritable bowel syndrome Specific Phobia (please specify below)	Obsessive Compulsive Disorder Tranquilliser Problems Panic Attacks/Disorder Post Traumatic Stress Disorder Other (please specify below)
Specify disorder/phobia

Newspaper/Magazine Article Radio ANXIETY UK website Social Worker Other healthcare professional NHS Direct MIND CALM Book (please specify below)	Television Internet (please specify website below) GP CPN Recommendation from friend or family Psychiatrist SANELINE Royal College of Psychiatrists Other (please specify below)
Specify book/website/other source

White Black African Asian Chinese Pakistani	Black Caribbean Black Other Indian Bangladeshi Other (please specify)
Specify ethnic background