Suunto Great London Swim

01 July 2017

Registration Form

To secure your place in the Suunto Great London Swim with Coeliac UK please return your completed form with £30 entry fee to the Fundraising Team

Personal Details

Membership No (if applicable): ______

First Name: ______

Surname:______

Address:______

______

Postcode: ______

Mobile Number: ______

Email Address: ______

Age on day of race: ______

Date of birth:______Male [ ] Female [ ]

Anticipated Finishing Time: ______

*Emergency Contact details:

Name: ______

Telephone Number: ______

Fundraising Motivation

Please clearly outline your reasons for applying to Coeliac UK for a charity place and why you wish to fundraise for us (you can continue on a separate sheet if needed)

______

How do you plan to hit your fundraising target? ______

Have you fundraised for Coeliac UK before? If so please give details.

______

How did you hear about Coeliac UK places in this event?

______

Fundraising interests

What other events would you be interested in getting involved with to raise funds for Coeliac UK? (please tick):

1)☐ Overseas Treks 2)☐ Parachute Jumps3)☐ Community Fundraising

4)☐ Cycling events5)☐ Running events6)☐ Individual Fundraising

7)☐ Walking events8)☐ Obstacle events9) ☐ Coeliac UK Raffle

10) Other (please specify) ______

Please tick if you are happy to receive information or email about taking on these events in future: Post ☐ Email ☐

Publicity

Would you be interested in talking to our media team and doing some PR around your story? Yes ☐ No ☐

We will send you a freerunning vest with the Coeliac UK logo, please tell us which of the below sizes you would like:

XSmall☐Small ☐Medium ☐Large ☐XLarge☐XXLarge☐

How to pay:

  • Enclose a cheque made payable to ‘Coeliac UK’
  • Make a bank transfer – please contact us for the details.
  • Call 01494 796724 (Monday to Friday, 9am-5pm) to make a debit/credit card payment over the phone.

Terms and conditions:

I would like to register for this event to exclusively support Coeliac UK. I am aware that once I have paid my £30 registration fee (inclusive of VAT), this will be non-refundable.

I understand that I am pledging to raise a minimum sponsorship of £200 for Coeliac UK (excluding Gift Aid) before the 6 week post-event fundraising deadline.

We would like to keep you updated about our fundraising successes, how we fund our work, and opportunities for you to support our work with a gift. To be included in these updates, please tell us how we can contact you:

Post - Yes ☐ No ☐Telephone - Yes ☐No ☐Email - Yes ☐No ☐

I have read and agree to these terms and conditions.

Signature ______

Date ______

Thank you for your application. Please email the completed form to or post it to the address in the footer of this application, marked FAO The Fundraising Team