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: Ted Hazelden, 23 Dunsdon Avenue, . GUILDFORD, GU2 7NX,

or via Mr James Robinson, 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this is for office use only and will NOT be published)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

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New student member form Mar10