Application Form: Run to the Beat
Sunday 13th September 2015
We’re delighted you’re interested in joining our team to support the Limbless Association.
As a charity, we have a limited number of places for the 2015 Run to the Beat. We ask all Team LA participants who receive a place to pledge to raise £100or more (excluding Gift Aid and registration fee). Our runners will receive a sponsorship pack and a t-shirt or running vest, along with all the support we can give along the way. If you can pledge to raise £100 or more, and would like to be considered for a place, please return your completed form to our Fundraiser (contact details below).
Entries will close on the 1st August 2015 unless the entry limit is met before.
Please complete all fields in capitals
- Personal Details
Title: ...... Forename: ...... ……..Surname: ......
Date of Birth: ...... Gender: ......
Address:......
......
...... Postcode: ......
Daytime telephone number: ......
Mobile: ......
Email: ......
Occupation: ...... Employer: ......
Does your employer intend to support you? (Please circle) YES NO
If yes, please provide details e.g. matched funding: ......
......
Have you supported the Limbless Association in the past (Please circle). YES NO
If yes, please provide details:
......
......
Where did you hear about running for the Limbless Association?
LA Website Run website Mailing/email Facebook/ Twitter Friend/ relative
Other (please specify ...... )
Do you have any running experience…………………………………………………………………………………………………………………………….
If yes, how many years………………………………………………………………………………………………………………………………………………….
How many miles a week are you currently running (approx.)......
Have you ever run a marathon or half marathon before? YES NO
If yes, what event did you take part in and what was your finishing time……………………………………………………………………..
- Run Details
What is your expected finishing time? ...... (hours/ minutes)
Are you running as part of a team? (Please circle) YES NO
If yes, please provide the other team members’ names below:
......
......
Are you planning to run in fancy dress? YES NO
If yes, please provide details: ......
......
Please send me a running vest or t-shirt
In size (Please circle) XS S M L XL
I’d like to run for the Limbless Association because: (Please continue on a separate sheet if necessary)
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......
......
......
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How much do you aim to raise for the Limbless Association? (Please note, we suggest a pledge of £100 or more)
......
Please outline how you plan to raise your sponsorship money e.g. holding your own events, sponsors, work, family and friends, local press etc.
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- Further contact info
Please indicate below as appropriate:
I’d be happy to talk to the Limbless Association about sharing my story to raise awareness. YES NO
I’d like to be kept up-to-date about the work of the Limbless Association. YES NO
I’d like to be kept up-to date about other fundraising opportunities YES NO
- Declaration
I am registering for the 2015 Run to the Beat. I pledge to raise a minimum of £100 for the Limbless Association. The money will be paid to the Limbless Association by no later than the 1st July 2015.
I confirm that I am at least 18 years old by 1stSeptember 2015.
Please find enclosed my registration fee of £35* (please make cheques payable to ‘Limbless Association’)
Sign** ...... Date: ......
*If you would like to pay by debit or credit card over the phone or by BACS transfer please contact Fundraiser Ed Pearce on the contact details below
**please note: we accept e-mail submission of this form as an electronic application
Thank you for taking the time to fill in this form.
Please email it to r return to:
The Limbless Association, Unit 10, Waterhouse Business Centre, 2 Cromar Way, Chelmsford, Essex, CM1 2QE
We will contact you as soon as possible to confirm receipt of your application.
Please don’t hesitate to contact us with any questions:
Tel: 01245 216 673
Email:
Charity No. England and Wales: 803533. Charity No. Scotland: SC042256
Thank you for your support