Team Cerebral Palsy Sport Guaranteed Place Application Form

Great North Run – Sunday 11th September 2016

Thank you for choosing to run the Great North Run for Cerebral Palsy Sport.

Please take a few moments to complete this application form, in block capitals, and return to Marianne Burchell, our Fundraising Officer, at the following address:

Unit 5, Heathcoat Building

Nottingham Science Park

University Boulevard

Nottingham

NG7 2QJ

Please try and give us as much information as possible.

There is an entry fee payable on application of £45 and we would also ask you to pledge to raise a target of £300in fundraising which would need to be with us by11th October 2016. This fundraising target does exclude any Gift Aid claimed from funds raised.

Title / Mr / X / Mrs / X / Miss / X / Ms / X / Other (Please state)
First Name / Surname
Home Address
Postcode / Employer’s Name & Address
Postcode
Date of Birth
(required for official entry) / D D / M M / Y Y Y Y / Occupation
Day Telephone / Eve Telephone
Mobile / Email
Some employers will help with sponsorship by ‘matched giving’, whereby they match, or part-match any funds that you raise. Does your employer operate such a scheme? / YES / X / NO / X
Predicted finishing time / Hours: / Minutes: / Seconds:
How many marathons / half marathons/10ks have you completed? / Marathons: / Half Marathons:
Your fundraising experience
If you have taken part in other fundraising activities please provide details below:
Date / Charity name / Amount raised / How did you raise this amount?
Where did you hear about fundraising for CP Sport?
Previous CP Sport event participant / X / CP Sport website / X / CP Sport email / X / Internet search engine / X
CP Sport event / X / Through family/friend/colleague / X / Other

Continued overleaf

Would you be happy for any photographs of you taken at the event to be used in future CP Sport publicity such as magazines/leaflets or our website? / YES / X / NO / X
How much do you pledge to raise for CP Sport in total (target£300)? / £
Details of how you would raise this amount? / Estimated £’s raised?
1.
2.
3.
If you have a link to CP Sport please give further details.
If there is something about your participation that would make a good media story (e.g. special birthday on the day or unusual occupation), please give further details.
Why do you want to run the Great North Run for CP Sport?
Please indicate the size of running top you will need.
MALE / Small / X / Medium / X / Large / X / X-Large / X
FEMALE / Small / X / Medium / X / Large / X / X-Large / X
Your declaration
Before submitting your application, please read through the full Terms and Conditions (overleaf) and sign the following declaration. By signing you agree to the Terms and Conditions overleaf.
I have read and agree to the full Terms and Conditions associated with the Guaranteed Place for CP Sport.
If offered a place, I confirm that I will pay the upfront non-refundable entry fee of £45and pledge to raise a target sponsorship of £300(exclusive of Gift Aid) for CP Sport. I understand that I must submit the full £300to CP Sport by 11thOctober 2016, and that if I have not raised the full amount by this date I may be asked to cover the remaining sponsorship myself.
Signed: / X / Date: / D D / M M / Y Y
Thank you for taking the time to complete this application form. We will acknowledge receipt of your form once it arrives in the office.
We never give your information to other organisations. Your details will be used by CP Sport. If you do not want to receive information about other ways to support CP Sport, tick here [ ] DPA
For Office use only /
Date received
/ Acknowledged / Offer / Accept / Notes

Terms and Conditions

If offered a guaranteed place, I will pay a non refundable registration fee of £45 and I commit to raise a target of £300. I understand that 100% of my sponsorship must be paid to CP Sport within 1 month of the event.

  1. Participants agree to pay CP Sport a non refundable registration fee to guarantee their entry.
  1. Participants agree to raise the target sponsorship specified for the event.
  1. Participants understand that if they have not paid the target amount to CP Sport by 13th October 2015 after completing the event they may be asked to make up the shortfall themselves.
  1. Participants agree to inform CP Sport immediately if they are unable to take part in the event.
  1. You must carry out your fundraising in accordance with guidelines set by CP Sport.
  1. CP Sport cannot take any responsibility for any injury, losses or damage caused or sustained as a result of fundraising events held in aid of CP Sport. It is the responsibility of the event organiser, to comply with legal and safety regulations. The event organiser for the Great North Run is Nova Inspiring Events.
  1. CP Sport may, at its discretion, withdraw a participant it believes that it is in the best interests of the charity to do so.

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