I want to be a Student Member!

Contact information

Gender First name Prefix Last name

Country Postal code / House no. / Suffix

Street City

Email address Birthdate (mm/dd/yyyy)

Communication preference Student number

Authorisation

IBAN I want to donate my 5 euro's to:

I hereby authorize the Leiden University Fund to deduct €5,- from my account each year. The authorization is valid until further notice.

Yes, I agree