176 Raddlebarn Road, Selly Park, Birmingham, B29 7DA
If this entry is part of a team, what is the Team Name?
(Please note we need a separate form completed for each team member – feel free to photocopy this form)
Which length run are you planning on doing? /
5km 10km
Address
Postcode
Email Address
Main telephone number
Alternative telephone number
Occupation / Employer
Name and telephone number of someone we can contact in an emergency
(Not someone participating in the race)
Do you have a particular reason for running for Birmingham St Mary's Hospice?
How did you hear about the Hospice Heroes Fun Run?
How much sponsorship are you hoping to raise?
What is the address of your online sponsorship page?
Any other comments?
Please use this space to tell us anything else interesting about you, information you think we should know etc.
Would you be happy for us to contact you for press and marketing purposes? / Yes / No
Entry fees / Entry fees are £10 for an individual or £30 for a team of 4 people
Is this an individual entry or team entry (4 people) ?
What is the Team Name?
Please charge my Visa / Electron / Mastercard / Maestro / CAF charity card delete as appropriate.
Card No □□□□ □□□□ □□□□ □□□□
Start Date□□□□Expiry Date□□□□
Issue No: □□Security No:□□□
(last 3 digits of number on back of card)
Name on Credit Card:
Signature of card holder:
Alternatively you can send a cheque(s) for the relevant amount. Cheques made payable to Birmingham St Mary's Hospice.
Conditions of entry
I understand that I am entering into this race by my own choice and that I confirm that I am in reasonable health and fitness and aged 12 or over on the day of the event.I am aware that the organisers, their employees and volunteers cannot be held responsible for any personal injury, accident, loss, damage or public liability. By signing the form I confirm that I have read and accept the conditions of entry to the Hospice Heroes Fun Run and the rules and conditions of this event. Entry forms that are not signed will be returned.
Signature:...... Date: /
(if aged 12-18, parental /guardian signature is required)
Data Protection Act: Your details will be held on the Hospice’s database and will not be sent to any third parties.We like to keep our supporters in touch with our news.
I don’t want to receive correspondence□ I don’t want to receive emails□ I don’t want to receive text messages□
Please return this form to Alice Higgins, Birmingham St Mary's Hospice,
176 Raddlebarn Road, Selly Park, Birmingham, B29 7DA
0121 472 1191