Forms Membership Declaration "*" indicates required fields Please complete the below form to submit your request.Member Name*Membership No.*Dependant Name ("Dependant")*InstitutionName of school, college or universityCurrent YearDeclaration Choice* I declare that the abovenamed Dependant: (a) Is a fulltime student attending the following school, college or university for the current calendar year: (institution name); (b) is under 25 years; and (c) unmarried. I wish to pay an additional amount on my membership (“dependant extension”) to maintain Dependant’s cover under the above membership. I declare that the abovenamed Dependant is: (a) under 25 years of age; and (b) unmarried. Please upload all relevant attachments. Drop files here or Select files Max. file size: 32 MB. I make this declaration that the information that I have supplied is true and correct.*SignatureThe above declaration is required to confirm that eligibility requirements for Dependant cover continue to be met. If your membership is paid via direct debit and a dependant extension option is selected, the direct debit amount will be updated as required to include this additional amount. PhoneThis field is for validation purposes and should be left unchanged.
