Charnwood

Smiles4Miles Fun Run

Entry Form

Fun runs for all ages and abilities across Leicestershire, Leicester & Rutland,

Fundraising for Red Nose Day

Use black ink and block capitals to fill in the form or better still complete and send by email. For more information see www.lrsport.org.uk/run

Closing date for postal entries is Friday 4th March 2011. Entry fees: Adults £5. Children under 16 £2. Family Entry (2 adults and 2 children) £12. Charnwood Borough Council will donate 50% of all funds from registrations to Red Nose Day. It’s your sponsorship cash that will help to change lives forever. To raise funds for Red Nose Day sign up at www.rednoseday.comor contact your local event coordinator to find out how to raise money for a local charity.

1.  Select your choice of distance (event details are listed overleaf)

2.  Provide your personal details

3.  List of additional entrants

Note: Family entries of 2 adults and 2 children under 16 only pay a total of £12. Family entry? Yes No

*Please provide a phone number for someone other than the people listed above that we can contact in the event of an emergency.

4.  Provide your payment (see overleaf for the payment options for your event)

I am paying by Cheque (see over for payment details) another method (please contact your Event Coordinator to make payment)

5.  About You

Over the past four weeks how many days a week, on average, have you taken part in 30 minutes or more of moderate intensity physical activity?

Zero One Two Three Four Five Six Seven

Are you... Male? Female? Date of birth: Ethnicity:

Do you have a longstanding illness or disability or infirmity? YesNo If yes, does it limit your activities in any way? YesNo

Event Details

District / Location / Date / Distances & Start Times / Event Capacity / Event Coordinator / Payment Options/ Cheques payable to
Charnwood / Loughborough Town Hall,
Market Place, Loughborough, LE11 3EB / Sunday 20th March / ·  3 miles; 10am
·  1 mile; 10.15am
·  Mascot dash before 3 mile event! / 250 / Helen Smith, Charnwood Borough Council, Southfield Road, Loughborough, LE11 2TX, / 01509 634673 / Online, cheques & cash payable to Charnwood Borough Council

6.  Sign the form: Declaration: By signing this declaration, I confirm that: I have read the Terms & Conditions, available at www.lrsport.org.uk/run. I am entering the event at my own risk and the event coordinator shall not be liable for any injury or loss that might occur as a result of my participation (this does not affect my statutory rights). I will seek medical advice if I have any doubts about my ability to take part. I consent to the use of my image in any TV or media coverage of the event and in any of the event coordinators promotional materials. I understand that entry fees are non refundable. I also confirm that the other people entered on this form have either read and agree to this declaration and the Terms & Conditions, or are under 18 and I am confirming this declaration on their behalf. Please tick if you do not wish to be contacted about sport and physical activity opportunities provided by Active Together and Local Authorities.

Closing date for postal entries Friday 4th March 2011

7.  Checklist. Have you...Listed the names of the people entering the event? Chosen the number of miles you’re doing? Enclosed a cheque or made arrangements for payment? Read the declaration and signed the form? Addressed your envelope to the Event Coordinator for your event?