Great Walls of Fire
Registration form
Push yourself to the limit in support of Inner Flame, a local youth charity making a huge
difference in young people’s lives. Join us at David Lloyd, Swindon on the 21st September as
teams attempt to climb the height of Mount Everest and cycle the distance of the Great
Wall of China; all in one day!
The Great Walls of Fire represents our biggest sponsored event yet! Choose to participate in
teams either climbing the height of Mount Everest or Cycling the distance of the Great Wall
of China. Participants should be in teams of 6-8 people for the Everest Challenge or 3-4 for
the Great Wall of China spinathon. If you do not have a team but wish to participate please
indicate this below and we will arrange a team place for you. Once your registration form is
processed you will be sent an information pack with fundraising tips and further details of
what to expect on the day. Each team member must commit to raising a minimum £50
sponsorship and pay a £10 deposit at the point of registration to secure their place. All
teams should appoint a team leader as a point of contact and if possible to ease the admin
process send all members forms together.
To register simply complete the following registration form and either hand it in to David
Lloyd Swindon reception or send it direct to Inner Flame with your deposit. The deposit is
refundable if you raise £100 or more.
Inner Flame is a local youth development charity that inspires and supports young people to
realise their potential. Funds raised will create opportunities for young people aged 14-24
to participate in our “Fire Me Up” & “Ignite” courses to build confidence, and find
motivation to achieve their goals.
We thank you for your support.
Great Walls of Fire
Registration form
Please register me for the Great Walls of Fire 2013
Your name:
……………………………………………………………………………………………
Company or Team name (if you are entering individually and would like to be placed in a
team please indicate that here):
……………………………………………………………………………………………
Who should we use as the main contact for your team?
…………………………………….
Please indicate which event you will be participating in:
Everest Challenge
Address:
Great Wall of China Spinathon
……………………………………………………………………………………………
……………………………………………………………………………………………
Postcode:
……………………………
Telephone no:
…………………………… Mobile:
E-mail:
……………………………………………………………………………………………
Signature:
…………………………… Date:
…………………………………..
……………………………….
Each application should consist of a completed registration form, disclaimer/consent form
and medical disclosure with a cheque covering the £10 deposit per application. Cheques
should be made payable to Inner Flame
Applications can be handed in at:
David Lloyd Gym Swindon, Latham Road, Blunsdon, Swindon, Wilts, SN25 4DL
Or posted to:
Great Walls of Fire, Inner Flame, The Shaftesbury Centre, Percy Street, Swindon, Wilts, SN2 2AZ
Charity number 1127750
Great Walls of Fire
Disclaimer & Consent form
Due to the physical nature of both events they inevitably involve risk of injury or medical
problems. Inner Flame and David Lloyd Leisure take all necessary precautions to try to ensure
the safety of participants, but accidents may occur.
You are responsible for being aware of the hazards, and helping to minimise these by behaving
sensibly and complying with the instructions given to you. We strongly recommend that you
train before this event, and seek medical advice beforehand if you don’t exercise regularly.
Please take care of your belongings on the day, as we don’t accept responsibility for any loss or
damage. There are lockers in the centre.
We will be filming and taking pictures during the event. These images may be published on the
Inner Flame website and Facebook groups. If you have any concerns about this, please cross
through the relevant consent clause or call us to discuss any questions. If you have any concerns
about filming during the event, we will stop and will not use any footage of you.
In signing this form:
 I understand and agree that I participate at my own risk.
 I consent to any treatment being given in an emergency.
 I give permission for staff from David Lloyd or Inner Flame to administer First Aid
and to take me to hospital if needed.
 I confirm that I will make Inner Flame staff aware of any medical condition that
may affect my involvement with the activities. (Please use the form overleaf.)
 I grant permission for my film/photo image to be displayed on the above-named
websites and/or in any related media or printed materials distributed by Inner
Flame.
Participant Name: …....................................
Signed: … ….……….……………………….………..……….
Date of Birth: ……....................
Date: …..................……
If you are aged under 18, we also need your parent or guardian to give their consent below.
Parent/Guardian Disclaimer:
I have read and understood the above information. The person named above has my
consent to participate in the Great Walls of Fire Challenge. I hereby agree to the
statements above.
Parent/Guardian Name: ………………………………
Relationship to Participant:…………………………….
Signed: ……….……….……………………….………..……….. Date:
……………………………..
In case of minor ailments (headaches etc), would you prefer us to offer:
Aspirin / Paracetamol / Nothing – please call me.
Great Walls of Fire
Medical Disclosure Form
Participant Name: ………………………………………………………..
Please indicate YES or NO to all of the following. Have you ever had or do you currently have:Any allergies?
Yes / No
Heart problems of any kind?
Yes / No
High blood pressure?
Yes / No
Recurrent back problems or surgery?
Yes / No
Epilepsy, seizures, convulsions or medications to prevent them?
Yes / No
Asthma, wheezing with breathing or wheezing with exercise?
Yes / No
Diabetes?
Yes / No
Any arm or leg problems?
Yes / No
Do you regularly take prescription or non-prescription medications?
(excluding contraception)
Yes / No
Are you pregnant?
Yes / No
If any of the above answers are “yes”, please provide further details here:
…………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………..
Is your Tetanus immunisation up to date?
Yes / No
Is there anything else that you think we should be aware of?
…….....………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
Emergency Contact
Please tell us who you would like us to contact in case of an emergency:
Name:
……………………………………………………………………………………………………….
Home phone no:
…………………………………
Mobile:
…………………………………………..
All details will be kept confidential and used only to make staff at Inner Flame,
David Lloyd Swindon and medical staff aware as required.