Basket Item Quantity Price Remove If you are a UK taxpayer your donation could be worth £0.00 at no extra cost to you. Yes - I am a UK taxpayer and would like to Gift Aid my donations now and in future. I understand I must pay enough income tax and/or capital gains tax each tax year to cover the amount of Gift Aid that all charities and community amateur sports clubs claim on my donations in that tax year, and I am responsible for paying any difference. Please remember to let us know if your tax status, name or address change or if you wish to cancel your Gift Aid declaration. VAT £0.00 Total £ 2. Payment method Please select a payment method. Free of charge Please authorize using the button below Card number * Don't forget your card number Your card number must be valid Expiry date (MM/YY) * Don't forget your expiry date Your expiry date is incorrect 01 02 03 04 05 06 07 08 09 10 11 12 / 19 20 21 22 23 24 25 26 27 28 29 30 Security code * Don't forget your security code Your security code must only include digits and there must be 3 or 4 of them Country where the card is registered Afghanistan Aland Islands Albania Algeria American Samoa Andorra Anguilla Anla Antarctica Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzevina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin isl. Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Rep. Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Con Con, the Democratic Republic of the Cook Islands Costa Rica Croatia Cuba Curacao !Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic Peoples Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Monlia Montenegro Montserrat Morocco Mozambique Myanmar/Burma Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion !Réunion Romania Russian Federation Rwanda Saint Barthelemy !Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovak Republic Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania Thailand Timor-Leste To Tokelau Tonga Trinidad-Toba Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands U.S.A. Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Please enter your postcode* Don't forget your postcode and address Your postcode is invalid Look up address or Enter address Street Please select Don't forget the first line of your address Address line 1 Address line 2 Don't forget your town or city Town or city Register Register using PayPal Details Title* Don't forget your Title Please start typing and select from the drop down First name * Don't forget your first name Last name * Don't forget your last name Email * Don't forget your email address Your email address has an invalid format Which country do you live in? Afghanistan Aland Islands Albania Algeria American Samoa Andorra Anguilla Anla Antarctica Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzevina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin isl. Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Rep. Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Con Con, the Democratic Republic of the Cook Islands Costa Rica Croatia Cuba Curacao !Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic Peoples Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Monlia Montenegro Montserrat Morocco Mozambique Myanmar/Burma Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion !Réunion Romania Russian Federation Rwanda Saint Barthelemy !Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovak Republic Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania Thailand Timor-Leste To Tokelau Tonga Trinidad-Toba Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands U.S.A. Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Please enter your postcode* Don't forget your postcode and address Your postcode is invalid Look up address or Enter address Street Please select Don't forget the first line of your address Address line 1 Address line 2 Don't forget your town or city Town or city Keeping in Touch At Brainwave, we’re committed to protecting and respecting your privacy. We would love to keep in touch with you. Your details will be kept safe and secure, only used by us, or those who work for us, and will not be shared with anyone else. If you would be happy to receive latest news, appeals and events from Brainwave, please tick the relevant box(es) below: Newsletter Fundraising Campaigns Events Please indicate how you would like to hear from us by using the tick boxes below: Via email Via telephone Your telephone number Please enter numbers only Don't forget your telephone number Via SMS Your mobile telephone number Please enter numbers only Don't forget your mobile number Via post Which country do you live in? Afghanistan Aland Islands Albania Algeria American Samoa Andorra Anguilla Anla Antarctica Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzevina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin isl. Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Rep. Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Con Con, the Democratic Republic of the Cook Islands Costa Rica Croatia Cuba Curacao !Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic Peoples Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Monlia Montenegro Montserrat Morocco Mozambique Myanmar/Burma Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion !Réunion Romania Russian Federation Rwanda Saint Barthelemy !Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovak Republic Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania Thailand Timor-Leste To Tokelau Tonga Trinidad-Toba Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands U.S.A. Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Please enter your postcode* Don't forget your postcode and address Your postcode is invalid Look up address or Enter address Street Please select Don't forget the first line of your address Address line 1 Address line 2 Don't forget your town or city Town or city Your Privacy We will always store your personal details securely. We will use them to provide the service that you have requested, and communicate with you in the way(s) that you have agreed to. If you would like to know more and understand your data protection rights, please view our privacy policy at: www.brainwave.org.uk/privacypolicy. You are free to change your mind at any time by emailing us on [email protected], calling us on 01278 429089 or writing to us at Freepost BRAINWAVE. An error has occured. Please refresh the page. Complete purchase By submitting this form you are agreeing to our terms and conditions This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. --