Required fields are marked with a *

Select New or Existing Member*
—Please choose an option—New MemberExisting member

Title*
—Please choose an option—MrMrsMsDoctorOther
First Name*

Last Name*

House Name/Number*

Road Name*
—Please choose an option—Lakeside WalkMarina TerraceMill LanePark AvenueQuaysideWaters View
Yarwell Mill
Yarwell
Peterborough
Post Code*

Main Telephone*....
Mobile Telephone..
Email Address*.......

If you are already a member of IPHAS, enter your number

Do you require IPHAS membership —Please choose an option—YesNo

Please select payment method. See details as to how below. —Please choose an option—Pay Direct to our Bank AccountChequeCash

Receive Email Notifications/Newsletters From IPHAS*........YesNo
Receive Email Notifications/Newsletters from YMCPRA*.......YesNo
(By ticking yes to receiving emails you agree to your Name, Address & email address being held on a secure database)

Signed* (Print your Name)

Date*

Our Bank details are:-
Account Name YMCPRA, Account no. 70742570 Sort code 20 63 28

We will contact you for cheque or cash payment.

This will clear the form and it will not be sent.