2014Virgin Active London Triathlon

Application form

August 2nd and 3rd 2014

To apply for one of our guaranteed places in the 2014Virgin Active London triathlonplease complete the form below.

It should be noted that St Elizabeth Hospice only has a limited number of places, therefore please complete your applicationas fully as possible. We will choose supporters whose applications reflect their commitment to fundraising for the Hospice.

Once you have completed this form, please take a copy for your own records and send to:

Fundraising, St Elizabeth Hospice, 565 Foxhall Road, Ipswich, IP3 8LX, email fax 01473 274717

St Elizabeth Hospice asks that each of their triathlon participants pays a registration fee of £30 and raises a minimum of £500

Personal Details

Title:______Name: ______Surname: ______

Address:______

______Postcode: ______

Day tel: ______Eve tel: ______Mob: ______

Email:______Date of birth: ______Age on race day:______

Prior to the event we will circulate a list of all those taking part for St Elizabeth Hospice so that you may get in touch with your fellow supporters. If you would like to be included in this list please confirm below the contact details you are happy to be disclosed to your fellow participants:

My address My telephone numbers My email

Estimated finishing time ______: ______: ______(hours : minutes : seconds)

If you have previously completed a triathlon, what was your best time?

_____ : _____ : _____ (hr:min:sec)

Employer Details

Occupation: ______Employer:______

Will your employer sponsor you?Yes No

Does your company provide Matched Giving?Yes No

About Your Fundraising Experience

We ask everyone awarded a Team St Elizabeth Hospice Charity Guaranteed Place to pledge to raise a minimum of £500. Please tell us how much you think you may be able to raise if awarded a place:

£______

Please detail two methods which you will use to enable you to raise this amount: Fundraising method______
______/ Estimated
£raised______
Fundraising method______
______/ Estimated
£raised______

Race categories

Which event would you like to take part in?

Category / Distances
Super Sprint (Saturday) / 400m swim, 10k bike, 2.5k run
Sprint (Saturday) / 750m swim, 20k bike, 5k run
Sprint Team Relay (each team member completes one leg) (Saturday) / 750m swim, 20k bike, 5k run
Olympic Team Relay (each team member completes one leg) (Saturday) / 1,500m swim, 40k bike, 10k run
Olympic Age Group (men’s) (Sunday) / 1,500m swim, 40k bike, 10k run
Olympic Mixed Group (Sunday) / 1,500m swim, 40k bike, 10k run
Olympic Open Age Group (Sunday) / 1,500m swim, 40k bike, 10k run
Olympic Plus (Sunday) / 1,500m swim, 80k bike, 10k run

Please note if you enter as a relay team a minimum sponsorship of £750 will be requested.

When securing a St Elizabeth Hospice Guaranteed Place you are confirming you agree to the Virgin Active London Triathlon race terms and conditions. To view the terms and conditions visit

St Elizabeth Hospice Running Kit

Please let us know which FREE piece of Team St Elizabeth Hospice kit you would like to run in:

MENSt-shirt OR running vest

LADIES t-shirt OR running vest

SIZEX Small Small Medium Large X Large

2014Virgin Active London Triathlon ballot

Have you entered the public ballot for a place?Yes No

If you are awarded a place through the public ballot, will you still raise money

for St Elizabeth Hospice?Yes No

If you are lucky enough to be awarded a place through the public ballot please let us know as soon as possible, so that we can award one of our Gold Bond places to one of the other applicants

Entry Confirmation

If awarded a charity place I will commit to raising at least £500 for

St Elizabeth Hospice by Friday 26th September 2014Yes No

I give permission to St Elizabeth Hospice to use any photographs/videos

taken of me to raise awareness and/or fundraising for the Hospice’s workYes No

Signed ______Date ______

We would like to keep you up to date with news and fundraising activities. If you would prefer not to receive this information please tick here