Coffee Club Sign Up Form

Coffee Club Join up form - This is not a direct debit you will still need to set up an automatic payment thanks.

Thank you for signing up for our Hospice South Canterbury Coffee Club. If you could please fill in the details below and also set up a regular payment to our bank account 03 0887 0348568 00 using the initials cc then your last name as a reference.
Once again Thank You, we love your community spirit.

Name *

First name

Last name

address *

Address line 1

Address line 2

Address line 3

Address line 4

Town/Suburb

City

Postcode/Zip

Home phone

Cell phone

Email address *

Age Group *

I would like to donate *

If other please let us know the amount and regularity thanks.

Can you please let us know how you heard about our Coffee Club?

We will be staying in touch with you over the year via email. Please feel free to contact us with any questions at any time.

We look forward to catching up with you at one of our 6 monthly coffee meetings if you choose to attend.

Thank you.