Sign-up service

About you^*

Date of birth

Contact details

Address

Ticket requirements

Number of chances each weekly draw

1 chance for £4.34 monthly

2 chances for £8.68 monthly

Bank details^*

Preferences

We would love to keep in touch with you about our work and how you can support it

Can we contact you by email? Yes No

Can we contact you by SMS? Yes No

Can we contact you by post? Yes No

Can we contact you by telephone? Yes No

Protecting your data

GDPR Statement

Your support makes our vital work possible. We'd love to keep in touch with you to tell you more about our work and how you can support it. We'll do this by the options you chose above and you can change these preferences at any time by calling or e-mailing us on 01332 785731 or uhdb.charity@nhs.net

We will never sell your details on to anyone else.

I have read and understood the above.^*

Problems with gambling?

For GamCare telephone 0808 8020 133

To self-exclude, please email: SelfExclusionDBH@TheFundraisingFoundry.com

Direct Debit

The Direct Debit Guarantee

This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits.
If there are any changes to the amount, date or frequency of your Direct Debit Derby & Burton Hospitals Charity will notify you (normally 10 working days) in advance of your account being debited or as otherwise agreed. If you request Derby & Burton Hospitals Charity to collect a payment, confirmation of the amount and date will be given to you at the time of the request.
If an error is made in the payment of your Direct Debit, by Derby & Burton Hospitals Charity or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society.
- If you receive a refund you are not entitled to, you must pay it back when Derby & Burton Hospitals Charity asks you to.
You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify Derby & Burton Hospitals Charity.

Instruction to your Bank or Building Society to pay by Direct Debit

Service user number

184345

Reference

For office use only

Instruction to your bank or building society

Please pay Derby & Burton Hospitals Charity Direct Debits from the account detailed in this Instruction subject to the safeguards assured by the Direct Debit Guarantee.

I understand that this Instruction may remain with Derby & Burton Hospitals Charity and, if so, details will be passed electronically to my bank/building society.

I confirm this direct debit instruction.^*

I accept the terms & conditions and privacy policy.^*

I confirm that I am aged 18 or over.^*

What happens next

Confirmation email

Check your email for confirmation of your sign-up. This email will provide more detail on what happens next.

If you cannot see our confirmation email, please check to make sure it hasn't been routed to your spam folder.

Please mark the email as from a legitimate source because we will be sending you another important email later containing confirmation of your direct debit, your ticket numbers and your first draw date.

Thank you for your amazing support.

Complete