The Biggest Loser 2016

Working in association with

Please ensure that you read the application form carefully and complete ALL questions. Entries must be received by midday on Friday 15th January 2016.

First Name: Surname:

Address:

Postcode:

Email:

Contact No:

DOB:

What are your reasons taking part in The Biggest Loser 2016?

What do you hope to achieve?

How much weight do you aim to lose?

What is the hardest thing for you about losing weight?

How much do you expect to raise in sponsorship? (Minimum £395)

How do you plan to raise this amount?

What is your reason for supporting St Luke’s Hospice?

Are you aware of any health reasons – or any other reasons – that might prevent you from doing or increasing the level of your physical activity? YES/NO

Have you had any operations in the last five years? YES/NO

If yes, please provide details here:

Do you suffer from back pain? YES/NO

Do you have any existing health conditions that will affect your availability to lose weight or exercise? (e.g. diabetes,asthma,epilepsy,bone/joint/back problems/high blood pressure) YES/NO

Do you suffer from any allergies or intolerances (e.g. wheat, dairy)

Do you have a heart condition? YES/NO

Are you currently taking any prescription medication, including antidepressants? (If yes, please list)

Are you pregnant, or do you have a child under 6 months old? YES/NO

Terms & Conditions (Please read carefully before committing yourself)

I, (please print name) ______confirm that:

·  I am 18 years of age

·  I commit to raising a minimum of £395.00 for St Luke’s Cheshire Hospice.

·  I commit to attending The Biggest Loser welcome event on Friday 22ND January

·  From Monday January 25th – Friday 22nd April 2016 I commit to attending every Monday group training session at BTB Fitness, Winsford from 6.00pm-7.00pm

·  I commit to attending the Biggest Loser social evening on Friday 4TH March 2016

·  I commit to attending the celebration event on Sunday 24th April at 4.00pm at the Abbey Wood Estate, Delamere

·  If I have to withdraw from the competition, the Hospice will use its discretion about payment of sponsorship owing, as we may not be able to fill your place

·  I understand that places are limited and filling out this application form does NOT guarantee my place

·  I understand that the Hospice has absolute discretion to select participants

·  I give my permission for my image to be captured by the Hospice and outside sources. I understand that these images may be used indefinitely to promote the work of St Luke’s Cheshire Hospice and its fundraising activities.

·  I will comply with all instructions given to me by the personal trainers at BTB Fitness and the event organiser. If I do not comply with those instructions or these terms and conditions, the Hospice may at its discretion require that I cease to take part in the training sessions/competition with immediate effect and without compensation to me

·  I understand that I am participating at my own risk. BTB Fitness personal trainers, are not employed by, or agents of the Hospice. Any service they provide to you constitutes a contract between them and you, not us and you. We accept no responsibility for breach of contract by, or negligence of, any such persons

Signed______Date______

St Luke’s Cheshire Hospice Limited and its subsidiary companies St Luke’s Promotions Limited and St Luke’s Trading Limited are registered under the Data Protection Act 1998.

The Hospice does not pass personal data to any other organisations, but may wish to keep you in-formed of Hospice news and activities. This includes mailings from us and our subsidiary companies, St Luke’s Promotions Ltd and St Luke’s Trading Ltd. If you would prefer not to be contacted please let us know by writing to St Luke’s (Cheshire) Hospice, Grosvenor House, Queensway, Winsford, Cheshire, CW7 2AY

Please return your completed form and photograph to Nicola Jepson, St Luke’s (Cheshire) Hospice, Grosvenor House, Queensway, Winsford, Cheshire, CW7 2AY

Please return your completed form to The Biggest Loser Challenge 2015, St Luke’s Cheshire Hospice, Grosvenor House, Queensway, Winsford, Cheshire CW7 2AY

OR email it to

Tel: 01606 555 815 Email: www.stlukes-hospice.co.uk Reg Charity No 515595