Lakelands Hospice

LAKELANDS HOSPICE

BRASS MONKEY 10k

SUNDAY 25th January 2015 11AM

@ Rockingham Speedway, Corby NN17 5AF

Entry Form

Please complete all sections of this form in block capitals. Closing date for forms is Thursday 22nd January 2015

Entry Fees: FUN RUN £5 (1 lap of Rockingham Speedway 1.5miles) FUN RUN STARTS AT 10.30AM

BRASS MONKEY 10k RUN - £12 (£2 reduction for Affiliated athletes £10)

ENTRIES MADE ON THE DAY - £15/£13

Please send your completed entry forms together with entry fee, cheques payable to “Lakelands Hospice” to : Race Organiser, Lakelands Hospice, Butland Road, Corby, Northants, NN18 8LX.

PART 1. Please provide your details in full:

Title: / First Name: / Surname:
Address: / Town:
County: / Postcode:
Age: / D.O.B
Daytime Tel: / Email:

PART 2 List all entrants (including yourself) and each person’s chosen distance to run (Fun Run or 10k) Please state if you belong to a running club.

Names (include your name) / Emergency Tel No. / 1.5 mile Fun Run / 10k / Affiliated with which club / Fee to Pay - £5 for Fun Run
10k £10 affiliated
£12 unaffiliated
1
2
3
4
Entry Fee Total: £

PART 3 Additional donations:

If you would like to make an additional donation to the Lakelands Hospice @ Home Care Appeal. Please write the amount here: / £

PART 4 Your total payment details:

Total amount to pay (entry fee/s plus donation if applicable): / £

Please make payable to ‘Lakelands Hospice’ and return with your completed entry form and if possible an A5 stamp addressed envelope

Credit/Debit Card Payments

Please visit www.runnersworld.co.uk to enter the Brass Monkey run online where there is a credit/debit card facility.

PART 6: Please read the following carefully and sign the declaration below. You will be signing on behalf of all participants on this form.

I declare that I am medically fit to take part in this event and I enter at my own risk. I will not hold the organisers or partner organisations responsible for any accident, damage or loss caused either before, during or after the fun run. I agree to abide by all rules and regulations as set out on the day of the event. I consent to any images of the event that may include pictures of me to be used in conjunction with any coverage or future promotion.

Signature (parent/guardian if under 16):______Date: ______

All proceeds from this event will support the Lakelands Hospice @ Home Care Appeal organised by Lakelands Hospice.

Registered Charity No.1062120. Lakelands Hospice, Butland Road, Corby, Northants, NN18 8LX