Pension Scheme at Princess Alice Hospice

Prudential RideLondon-Surrey 100Sunday 30 July 2017

Application form

Thank you for your interest in taking part in the RideLondon-Surrey 100 for Princess Alice Hospice.

Things to know before filling out this form
· We only have 28 guaranteed gold bond charity places, so unfortunately not everybody will be successful. Places will be offered on a first come first served basis.
· We ask all our cyclists to pledge to raise £650 in sponsorship.
· As well as applying for a charity place, you can also enter the RideLondon public ballot on their website. The ballot is open until Friday 6 January 2017 or when 100,000 applications have been received.

Personal details

Title: / First name:
Surname:
Address:
Postcode:
Tel No. (Day): / Tel No. (Evening):
Email address:
Date of birth:
Place of work/education:
Does your place of work offer any form of match funding schemes? / Yes / No
Preferred vest size / S / M / L / XL / XXL

Questions

1. Why have you chosen to support Princess Alice Hospice?
2. What would your personal sponsorship target be?
(Our Gold Bond places have a sponsorship pledge of £650)
3. Please list some examples of how you intend to raise this money?
4. Have you participated in any other sponsored events? If so, please provide us with examples, the charities you supported and how much you raised.
5. Do you have any sport related injuries that we need to be aware of?
6. What time would you hope to complete the cycle in?
7. Do you belong to any groups or clubs?
8. How did you hear about Princess Alice Hospice and our RideLondon places?
9. Would you be interested in having a tour of the Hospice? / Yes / No
10. Have you applied for a ballot place in Prudential RideLondon-Surrey 100 this year? / Yes / No
11. If you are successful in getting an official ballot place would you choose to cycle for Princess Alice Hospice? / Yes / No
12. Are you applying for any other Gold Bond places with other charities? / Yes / No

Payment details

The registration fee for RideLondon-Surrey 2017 is £30.

I accept that if I am allocated a Charity Bond Place, I will pledge to raise £650 in sponsorship for Princess Alice Hospice in addition to the £30 registration fee.

Please find enclosed a cheque made payable to Princess Alice Hospice.

Or complete your credit/debit card details below:

Please debit my Visa Master Card Delta

Card number

Start date Expiry date Security number

Print name: Date:

Signed:

Please return your form either by post or email.

Post: RideLondon, Supporter Care, Princess Alice Hospice, West End Lane, Esher, Surrey KT10 8NA

Email:

Princess Alice Hospice is a registered charity no 1010930 and a company limited by guarantee in England & Wales no 1599796 1