Instruction to your Bank or Building SocietyPlease pay Birmingham Hippodrome Direct Debits from the account detailed in this instruction subject to the safeguardsassured by the Direct debit Guarantee. I understand that thisInstruction may remain with Birmingham Hippodrome and, if so,details will be passed electronically to my Bank/Building Society.

BANK/BUILDING SOCIETY ACCOUNT NUMBER:

ORIGINATOR’S IDENTIFICATION NUMBER:

8 | 3 | 0 | 9 | 0 | 8

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REFERENCE (to be completed by Birmingham Hippodrome):

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Name and full postal address of your Bank or Building Society

TO: THE MANAGER BANK/BUILDING SOCIETY:

ADDRESS:

EXPIRY DATE: DATE PROCESSED:PROCESSED BY:

(To be completed by Birmingham Hippodrome)

Instruction to your Bank or Building Society to payby Direct Debit

Please fill in the whole form using a ball point pen and send it to:

Birmingham Hippodrome Patrons

Birmingham Hippodrome

Hurst Street

Birmingham

B5 4TB

Please read this guarantee information before signing. A copy of this will be sent to you for your records.

The Direct Debit Guarantee

NAME(S) OF ACCOUNT HOLDER(S):

BRANCH SORT CODE:

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POSTCODE:

SIGNATURE(S):

DATE:

BOOKING REF:

• This guarantee is offered by all Banks and Building Societies that take part in the Direct Debit Scheme.

The efficiency and security of the Scheme is monitored and protected by your own Bank or Building Society.

• If the amounts to be paid or the payment dates change, Birmingham Hippodrome Theatre will notify you ten working days in

advance of your account being debited or as otherwise agreed.

• If an error is made by Birmingham Hippodrome Theatre or your Bank or Building Society, you are guaranteed a full and immediate

refund from your branch of the amount paid.

• You can cancel a Direct Debit at any time by writing to your Bank or Building Society. Please also send a copy of your letter to us.

As a registered independent charity (No 511567) Birmingham Hippodrome relies onincome from ticket and ancillary sales and the generous support of donors like you.

Your support really does make a difference:

“I thought it was brilliant. Just brilliant.I’ve waited 9 years to be able to take my autistic daughter

to the theatre and for her to enjoy it”AUDIENCE MEMBER, RELAXED PERFORMANCE

“It’s clear that Dance Quest was a stonking success.I’m absolutely over the moon about that.Well done”

JEREMY NEWTON, CHIEF EXECUTIVE, THE PRINCE’S FOUNDATION FOR CHILDREN & THE ARTS

“I enjoy being part of the Hippodrome Family. Being involvedin the Relaxed Performance and watching the faces of the

audience was magical, the special care shown byeveryone at the Hippodrome is a joy”

CURRENT PATRON

Details about Birmingham Hippodrome, its charitable activities and its trustees

can be found online at birminghamhippodrome.com

Birmingham Hippodrome Development Trust is a registered charity (No 511567)All details correct at the time of going to print

PLAYYOURPART

Patrons

From as little as £25 a month, your contribution will directly fund thedelivery of our creative and education programmes via

Become a Patron to receive fantastic benefitsand exclusive access to the theatre you love.

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TITLE:

TELEPHONE (DAY/EVE):

EMAIL:

ADDRESS:

POSTCODE:

FORENAME/INITIALS: SURNAME:

YOUR DETAILS

BECOME A PATRON PLEASE COMPLETE THIS FORM AND RETURN IT TO THE ADDRESS OVERLEAF

PAYMENT DETAILS

GIFT AID DECLARATIONYour membership may qualify for Gift Aid, please sign below if you are eligible.I would like Birmingham Hippodrome (Registered Charity number 511567) to treat all donations I have made since 6 April 2008 and all donations I make hereafter as Gift Aiddonations, unless I notify you otherwise. I confirm I have paid or will pay an amount of Income Tax and/or Capital Gains Tax for each tax year that is at least equal to the amountof tax that all charities I donate to will reclaim. I understand that other taxes such as VAT and Council Tax do not qualify. I confirm I will notify Birmingham Hippodrome if I wish tocancel this declaration, if my name or address changes or if I no longer pay sufficient tax as described above.

SIGNATURE:

MEMBERSHIP DETAILS

NAME OF JOINT MEMBER (IF APPLICABLE):

Hippodrome Circle Patrons£3,000 OR MORE ANNUALLY

Or 10 instalments of a minimum of £300

Headline Act Patrons£1,400 - £2,999 ANNUALLY

Or 10 instalments of a minimum of £140

Leading Role Patrons£700 - £1,399 ANNUALLY

Or 10 instalments of a minimum of £70

Supporting Cast Patrons£250 - £699 ANNUALLY

Or 10 instalments of a minimum of £25

FROM

£300A MONTH

FROM

£140A MONTH

FROM

£25A MONTH

Our highest level supporters receive all of the Supporting Cast benefits (below) plus:• Ticket credit of £200 a year •

• Unlimited use of our Qdos Lounge on show nights for up to 4 people • • Two complimentary uses of a private hospitality suite during an evening performance •

• Exclusive invitations from our Chief Executive and Trustees • • A private backstage tour on joining •

• The opportunity to Name a Seat in our auditorium on joining •

Headline Act Patrons receive all of the Supporting Cast benefits (below) plus:• Ticket credit of £175 a year •

• Unlimited use of our Qdos Lounge on show nights for up to 4 people •• Two complimentary uses of a private hospitality suite during an evening performance •

• Invitations to Gala Dinners and Guest Evenings •

Leading Role Patrons receive all of the Supporting Cast benefits (below) plus:• Ticket credit of £90 a year •

• Use of Qdos Lounge on show nights up to 4 times a year for up to 4 people •• Invitations to Gala Dinners and Guest Evenings •

Supporting Cast benefits include:• Advance show information • Priority booking and a personalised booking service •

• Special ticket offers with no transaction charge or exchange fees • Access to sold out shows up to a week before •• Discounted dining in the Circle Restaurant, StageSide and the Deli Bar •

• Three complimentary programme vouchers • Invitations to special Patrons events •• Accreditation in key publications •

FROM

£70A MONTH

Either I wish to pay £ by ANNUAL Direct Debit (PLEASE COMPLETE FORM OVERLEAF).

or I wish to pay £ in TEN INSTALMENTS by Direct Debit (PLEASE COMPLETE FORM OVERLEAF).

or I enclose £ by CHEQUE made payable to Birmingham Hippodrome.

or I wish to pay £ by credit/debit card. Please call me on my contact number I have provided

to take my payment details (please do not email credit or debit card details).

I wish to join Birmingham Hippodrome’s Patrons Scheme at the following level: (PLEASE TICK PREFERRED LEVEL)

Supporting Cast £250 - £699 A YEAR Leading Role £700 - £1,399 A YEAR

Headline Act £1,400 - £2,999 A YEAR Hippodrome Circle £3,000+ A YEAR

Amount £

N.B. your contribution must be at least equal to the starting value of the Patron level you have selected

Please include an additional donation of £ with my membership (PLEASE COMPLETE A GIFT AID MANDATE BELOW)

I wish to decline all benefits and make my total contribution a donation (PLEASE COMPLETE A GIFT AID MANDATE BELOW)

51,000 people attended freeperformances and events

19,000 participants engaged with ourCreative Learning Programme

1,400 attended access performances,talks or tours

14,000 discounted tickets were providedfor school children

Data taken from our Performance Review, 2013-2014.

DATE:

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