HarmUni/Eboracon Membership Form

Real Name:         ................................................

Badge Name:        ................................................

Address:           ................................................

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Postcode:          ................................................

Email:             ................................................

Phone (optional):  ................................................

Membership     Attending               £25
Type:          Student/unemployed      £20
               Supporting              £10
               Child (5-16)            £10

All cheques should be made payable to "Eboracon"

Lissa Allcock
119 Whitehill Lane
Gravesend
Kent DA12 5LU