THE ASHCOMBE DORKINIAN ASSOCIATION

 

I wish* / do not wish* to become a member of The Association

Please complete ALL sections and return the ENTIRE page

 

To A.D.A. Membership Secretary: Peter George, Redshanks,

West Street, LILLEY, Herts, LU2 8LH.

or via Mr Ben Blackband, Head of Sixth Form

 


Name/ Initials : Surname: .

 

Address : ..

 

 

Post Code: ..

Years at School From to ..

 

 

We send ADA Newsletters via Email if we have an address for you . (About 2 or 3 times a year)

 

Email Address: ...

 

I wish*/do not wish* my email address to be published in the Association Membership List

 

Telephone number

 

this is for office use only and will NOT be published)

 

I am */ I am not* applying for the ADA Bursary Award this year.

 

Any comments you wish to make:

 

 

 

 

 

 

 

Your Signature Date

 

New student member form Mar16