St George’s Hospital Charity

VIRGIN LONDON MARATHON 2018

22ndApril 2018

GOLDEN BOND APPLICATION FORM

Registered charity number: 1171195

If you would like to be considered for one of our Golden Bond places, please complete this form and return it to us. We ask that runners pledge to raise a minimum of £2,500.

Please read the following before applying for guaranteed charity place in the London Marathon:

Please note, completing the application form for acharity placedoes notguarantee you a place in the Virgin Money London Marathon 2018. By filling in the form, you are joining our waiting list and we will get in touch with you shortly to inform you if you have been successful.

Once a place has been offered to you, you will be required to make payment of the £75registration fee within 14 days. We choose runners based on their reasons for running and ability tocommit to meeting the minimum sponsorship amount. Please be specific abouthowyou plan to raise the £2,500 minimum sponsorship amount, e.g. £500 from race night, £100 from cake sale at work, etc.

Personal Details

Full name:

Home Address:

Postcode: Date of birth

Mobile: Email:

Please tick if you are happy for us to contact you by e-mail. This helps reduce our costs

Occupation: Company:

Does your place of work provide matched giving for the sponsorship you raise? Yes No

(If you’re not sure, please ask as it can significantly boost your target)

Entry information

Have you applied to the official ballot? Yes No

If you get a place in the ballot would you still like to raise some money for St George’s?

Yes No

Why do you want to run for St George’s?

Do you have a link with St George’s Hospital Charity or St George’s Healthcare NHS Trust?

If so, please give details

Would you like to fundraise for the St George’s Hospital Charity ‘Better Everywhere’ appeal (whereby we will use your fundraising wherever there is the greatest need) or is there a particular part of the hospital that you would like to raise money for?

How did you hear about the St George’s Hospital Charity Golden Bonds?

Fundraising information

Have you taken part in the London Marathon before? Yes No

If yes, did you raise money for charity? Yes No

Were you running with a Golden Bond? Yes No

Name of charity ______Amount you raised £

If no, have you raised money for a charity before? If, yes please give details

Fundraising plans

We ask that our Golden Bond runners pledge to raise at least £2,500. Detail below how you plan to raise the money listing more than one method. Please continue on separate sheet if necessary

We ask that our runners wear our charity t-shirt or running vest on the day. Please state which you would prefer and your size

Running Vest T-shirt Size: S M L XL

I agree for my photograph or story to be used for publicity purposes Yes No

Declaration

  • I understand that if I am accepted for a St George’s Hospital Charity Golden Bond I am undertaking a pledge to raise a minimum amount of £2,500 to be collected by 22ndMay 2018
  • I understand that if I am accepted for a St George’s Hospital Charity Golden Bond I will be required to pay a non-refundable registration fee of £75
  • I confirm that I have/ haven’t entered the official ballot
  • I declare that to the best of my knowledge I am in a good state of health and take full responsibility for myself

Signature ______

Date ______

What happens next?

Please make sure we get your completed form by 1 October 2017

Results of the official ballot are announced by the race organisersin early October. We will contact you by the end of October to let you know if you have a Golden Bond place with us.

Please contact us when you receive your ballot result!

If you are successful and win a place in the ballot please contact the Fundraising Team on 020 8725 4522or email

To maximise the money raised our guaranteed places are awarded on merit of fundraising proposals.

GOOD LUCK!

Please return this form to Fundraising, St George’s Hospital Charity,

St George’s Hospital, Blackshaw Road, London, SW17 0QT

Or

email a scanned copy to:

Find us on Facebook: St George’s Hospital Charity

Follow us on Twitter: @GivingtoGeorges