BRIGHTON MARATHON

Sunday 15 April 2018

CHARITY PLACEREGISTRATION FORM

Registered charity number: 1171195

If you would like to be considered for one of our places, please complete this form and return it to us. We ask that runners pledge to raise a minimum of £600.

Once a place has been offered to you, you will be required to make payment of the £25 registration 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 £600 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. We would also like to send you newsletters. 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 for a General Entry place?Yes No

If you get a General Entry place would you still like to raise some money for St George’s?

Yes No

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

Would you like to fundraise for the St George’s Hospital Charity General Fund or is there a particular part of the hospital you would like your money to go towards?

Do you have a link with St George’s Hospital Charity or St George’s University Hospitals NHS Foundation Trust? If so, please give details

How did you hear about the St George’s Hospital Charity places in the Brighton Marathon?

Fundraising information

Have you taken part in a Marathon before? Yes No

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

Were you running with a Golden Bond/Guaranteed Place? 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 runners pledge to raise at least £600. Please detail below how you plan to raise the money listing more than one method. 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(please circle one)

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 PlaceI am undertaking a pledge to raise a minimum amount of £600 to be collected by 15 May2018.
  • I understand that if I am accepted for a St George’s Hospital Charity place I will be required to pay a non-refundable registration fee of £25.
  • 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 by31 October 2017.

We will contact you by the beginning of November to let you know if you have been successful in gaining one of our places.

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:

* For any challenge event we strongly recommend that you consult a GP. *

St George’s Hospital Charity (registered charity number 1171195)

Martyn WillisChief Executive, Anna WalkerChair of the Trustees