Name______________________

Address_______________________________________________________________________________

Post Code_________________

Telephone Number_________________

Email Address____________________________

Please accept my donation of: £6.30 - A penny for every kilometre cycled _____ £10 - £1 for every day of cycling _____ Any Other Amount _____

Please make all cheques payable to Children Nationwide - we/ll also accept cash but please still state the amount you're sending.

Using gift aid you can make your donation worth more. For every pound you give, Children Nationwide can get an extra 28p from the Inland Revenue. So just sign below - it's that simple!

Signature______________________ - I would like Children Nationwide to claim back the tax on this and any future donation. To qualify for Gift Aid, what you pay in income tax or capital gains tax must equal the amount the charity claim in a tax year.

Please post your form to: Cycle Vietnam 2003, C/O Riverfort Cottage, 25 Frog Lane, Titchfield, Hants, PO14 4DU UK

Children Nationwide is registered as Children Nationwide Medical Research Fund; registered charity number 289600