Great North Run

Sunday 11th September 2016

Team Cash for Kids – Place Application Form

Cash for Kids has a number of Guaranteed Entry Places in the

Great North Run 2016 but they are always in great demand.

If you would like to be part of Team Cash for Kids and raise funds for disabled and disadvantaged children, please complete this form

1.  Personal Details:

Title ______First Name ______Surname ______

Date of Birth ______Vest Size ______

Address ______

______Postcode ______

Tel No. (work) ______(home) ______

Email (needed for registration) ______

2.  Deposit/Fundraising

Cash for Kids requires a £50 non-refundable deposit to secure your entry in the Great North Run 2016 with a pledge to raise a minimum of £350 sponsorship

·  The deposit can be made using the below link. Please state in the comment box that this is a GNR deposit

https://www.cashforkidsdashboard.co.uk/scottish-borders

·  Or by cheque made payable to ‘Cash for Kids’

·  Or by phone to 01896 759 444

Because of the high costs of purchasing places for The Great North Run, the charity must ensure all fees are covered. By ticking the following, you are agreeing to these terms:

I confirm that I can raise the pledge amount of £350

I agree that if I drop out after the final registration date in July or fail to take part in the run, without officially deferring my place with the race organisers, I will pay the charity half of my pledge £175

Please sign to show you agree to these terms

Signed______Print Name ______

We recommend you set up fundraising page at the below link to join our team http://www.everydayhero.co.uk/event/gnr-metroradio2016

Alternatively we can provide sponsorship forms on request.

3.  Interesting Story

We are often asked by the media for ‘interesting stories’ about our runners. This may range from personal reasons why people are running to those who run in fancy dress!

Do you have an ‘interesting story’ you would like to share?

______

______

______

4.  Medical Information

By signing this registration form you declare that:

I am familiar with the nature of the activity which I wish to undertake and acknowledge all of the risks involved. I understand and accept that I take part entirely at my own risk and that the organisers accept no liability for death or injury unless caused by their negligence.

I hereby declare that I am in good health, and that I am not suffering from any medical condition or disability that might make it unsafe for me to take part in the event. I accept that I shall be solely responsible for any decision as to my fitness to participate.

I also give my permission for photographs which are taken of me during the event to be used to publicise future events.

PLEASE WRITE CLEARLY IN BLOCK CAPITALS

Emergency contact …………………………………………………………………………………………….

Relationship ………………………………………………………………………………………………………..

Emergency Tel ……………………………………………………………………………………………………

5.  Declaration:

I hereby absolve Cash for Kids & Radio Borders of responsibility for any loss or injury caused to myself through my participation in the Great North Run 2016.

Signed ______Date ______

Please sign and return with payment to;

Candy Rafferty

Cash for Kids, Radio Borders, Tweedside Park,

Galashiels, TD1 3TD

Or email back to

(Please photocopy this form if required)