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If you have any problems competing this form, please call us on 0800 980 4800 to make your donation over the phone.

Please choose one of the options below *

• Regular monthly donation
• Single Donation

Please choose one of the options below

• £3 per month
• £5.00 per month
• £10.00 per month
• Other

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£ 0.00

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By selecting Regular Gift you have chosen to make a monthly donation.

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ExpirationMM123456789101112/YY2324252627282930313233

If you are a UK tax payer and this donation is a single payment from yourself (and not a collection from friends or colleagues), Jeans for Genes Day can add Gift Aid to your donation. This means we can reclaim the tax. Please select the tick box below if you would like to Gift Aid your donation.

• Yes I would like Jeans for Genes to claim Gift Aid
• No I would not like Jeans for Genes to claim Gift Aid

I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all of my donations in that tax year is my responsibility to pay any difference.

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