ENTRY FORM: Great North Run 11September 2016

Title / Name / Surname
Mobile No / Email
Vest Size / FEMALEXS32S34M36L38XL40 MALES38M40L42XL44XXL46
DOB / / /
Name letters for front of vest (ie jo)
Why do you want to fundraise for ERUK?
Where did you hear of our work?

All applicants must be over the age of 17

I enclose a cheque for £30for the Great North Run 2016.(made payable to Epilepsy Research UK)

I paid £30 registration by phone/via the ERUK website

Please debit my card (details as follows) for £30

Card type
Cardholder's name
Card number / Issue No (switch only)
Expiry date (mm/yy) / Security No on back of card
Start Date (mm/yy)

 I agree to the race terms and conditions as set out by the Great North Run ( and agree to officially enter online as soon as the email link has been emailed to me. I understand that failure to redeem the voucher results in my entry being void and the place being offered elsewhere.

I agree to raise the minimum sponsorship amount of £300.

Signature / Date


ERUK cannot be held liable for death, personal injury, loss or damage as a consequence of my entry into the Great North Run 2016.ERUK is unable to offer advice about training. It is strongly recommended that you train for the run and prepare for the challenge. If you have not exercised before or for some time, consult your doctor for a check up. If you have a medical condition, please complete the details on the back of your race number.

Entries are non-transferable and non refundable.

ERUK will contact you with regards to the details of the Great North Run and would like to keep you informed about our work.

If you would prefer not to receive to our monthly research e-newsletter please tick here 

If you would prefer not to receive our quarterly Focusnewsletter by post, please tick here 

Please return this form together with your paymentby email to or post to:

Epilepsy Research UK, PO Box 3004, London, W4 4XT

Epilepsy Research UK, PO Box 3004, London W4 4XT

t: 020 8747 5024 f: 0870838 1069 e: w:

Registered office: Chiswick Town Hall, Heathfield Terrace, Chiswick, London W4 4JN. Registered charity no: 1100394