Challenge Event Registration Form 2013
To help us offer the best available support for your challenge or
fundraising activity, please complete and sign this form and return it to
us at least 4 weeks in advance of your event to the address given.
Challenge Outline
Challenge Category:
Running / Cycling / Triathlon / Swimming / Other: ………………………………….….
Name of Challenge:………………VIRGIN LONDON MARATHON 2014…….(BALLOT)……………………………..
Date of Challenge: ..13…/……04..…/…2014..Location of Challenge:…………London ……………..……………….
How did you find out about this particular challenge?...........................................................................
Personal Details (Please use CAPITAL LETTERS)
Title (Mr/Mrs/Ms/Miss/Dr/Other)…………..Name……………………………………………………………………………….
Address………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………..
Postcode:…………………………….Email:…………………………………………………………………………………………………..
Daytime Telephone:………………………………………………….Mobile:…………………………………………………………..
Date of Birth:………………………………………………… Sex: Male / Female (please circle)
Occupation:……………………………………………………Company:……………………………………………………………….
T-shirt
Running Vest
(Select One)
Size: XS / S / M / L / XL ………………………
Challenge Application
I already have a place in this challenge and I would like to fundraise for Genetic Disorders UK
(GDUK)/Jeans for Genes Day*
I am applying for a GDUK * charity place
Fundraising
We would be grateful if you provided information regarding the following questions.
1.
How did you hear about Genetic Disorders UK?
2. Do you have a personal reason for choosing to support the charity? (Associated genetic
condition that has affected family/friends)
3. How much you pledge to raise for Genetic Disorders UK?
4. Describe 3 ways in which you hope to raise your sponsorship?
1.
2.
3.
5. Do your company provide matched giving?
Yes / No / Not sure will look into it
6. Have you ever taken part in a fundraising event before? If so, please let us know what it
was.
7. Would you be willing to contact your local media to publicise your fundraising for Genetic
Disorders UK?
8. What time are you hoping to achieve to complete your event?
…………………………hrs…………………………mins
Please feel free to attach further comments to questions
DECLARATION OF FUNDRAISING INTENT FOR EVENT PARTICIPANTS
I,…………………………………..(name) agree that as a ballot runner who is supporting Genetic Disorders UK
(GDUK )* for Virgin London Marathon 2014 I will agree to abide by the following terms and
conditions:
EVENT REGISTRATION AND FUNDRAISING
1. I accept that GDUK are authorised to contact me regarding my sponsorship activity from
completed registration with the charity.
2. I pledge to fundraise to help children with genetic disorders. I understand that all
sponsorship should be returned to GDUK no later than 3 months after the date of the event.
3. I understand that my sponsorship does not include Gift Aid.
EVENT PARTICIPATION
1. I agree to take part solely and exclusively for GDUK, registered charity number 1141583,
unless agreed beforehand with the charity.
2. I understand that I have a responsibility for ensuring my own fitness and health to
participate in the event and will honestly declare all medical details below.
3. In the event that I am unable to compete, I will inform a member of the GDUK team as soon
as possible.
I have read and understood the above and accept these terms and conditions.
Name (Block Capitals): …………………………………………………………………………………………………………………..
Signature:……………………………………………………………………………………….Date:……………………………………..
Medical Declaration
Please indicate below if you have any pre – existing medical conditions or are on medication.
Pre-existing medical conditions, details of hospital treatment in the last 12 months, current medication required, allergies.
How can we help?
Would you like to receive more information on Jeans for Genes Day – Friday 20th September? Y / N
Please tick which of the following you would like to receive:
Sponsor Form
Letter of Authenticity
I would like more information on:
Stickers
Leaflets
Jeans for Genes Day
Genetics Disorders UK and its associated charities
Collection Box
Other Challenge Events
Educational Resources
Recommend a Friend
If you know someone who would like information about the event you are taking part in and they
have authorised you to provide their details, please let us know below:
Name:……………………………………………….Email:…………………………………………………………………………………
(NOT REQUIRED FOR BALLOT PLACE) PAYMENT SECTION
Genetic Disorders UK provide two methods of payment for registration deposits.
Online
Please go to http://www.jeansforgenesday.org/donate and select
Make a Donation
Choose your payment option preference and complete the online payment form.
Once your transaction has been processed and you have received your Receipt Email forward this to
Hayley@geneticdisordersuk.org
Offline
Please send all cheques made payable to Genetic Disorders UK and must be referenced with your
name and the event you are participating in.
Send all payment to:
Hayley Banyard
Events Coordinator
Genetic Disorders UK
199A Victoria Street
London
SW1E 5NE
If you require assistance in completing this form or if you would like to discuss your fundraising
activity please call the Genetic Disorders events support on 0207 199 3316.
Jeans for Genes Day raises money for Genetic Disorders UK.
Genetic Disorders UK is a charitable organisation registered in ENG&WAL with registered charity number 1141583
& company number 7564771.