Contact Information

State / Province*
Confirm Email*

Under 18? We will need a parent or guardian to sign a printed version of this form, please email for a copy. 

Date of Birth (dd/mm/yyyy)
Date of Event (DD/MM/YYYY) Please estimate if date unconfirmed at this stage*
If the above date is an estimate, please provide details here.
What is your fundraising event?*

Gift aid 

Boost your donation by 25p of Gift Aid for every £1 you donate
Gift Aid is reclaimed by the charity from the tax you pay for the current tax year. Your address is needed to identify you as a current UK taxpayer.

In order to Gift Aid your donation you must tick the box to confirm you are UK taxpayer and understand that if you pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all my donations in that tax year it is your responsibility to pay any difference.


If you pay Income Tax at the higher or additional rate and want to receive the additional tax relief due to you, you must include all your Gift Aid donations on your Self-Assessment tax return or ask HM Revenue and Customs to adjust your tax code.

It is important to us to be able to engage with you and keep you up to date with the latest news about encephalitis and our work.  This might include fundraising and research or other aspects of our work that help us meet our primary aim of improving the quality of all lives affected by this often-devastating condition. Please tell us how you prefer to hear from us and the different ways that we can keep in touch with you.

Consented to be contacted via*
  • Post
  • Email
  • Telephone
  • Does not consent (details removed)
Contact Preference*
  • Email
  • Post
  • Telephone
About you*
  • Bereaved
  • Family Member
  • Friend
  • Parent
  • Person Affected
  • Supporter

Be Safe, Be Legal


If you wish to fundraise in support of the Encephalitis Society you MUST agree to the following: 


1) To read and abide by the contents of the Encephalitis Society's fundraising guide


2) To only use lawful means to fundraise and not to do anything that will harm the Society's reputation


3) To pay in all money raised for the Society within 30 days


4) To be responsible for managing risk, organising insurance and obtaining relevant permissions for all aspects of your fundraising activities


5) To accept that the Encephalitis Society is NOT responsible for my fundraising acitivities and will not be held liable in any way


  • I agree
Additional Comments