The Evelina Children S Hospital Appeal

The Evelina Children S Hospital Appeal

St George’s Hospital Charity Abseil, Saturday 16th September 2017 Registration Form

If you would like to take part in the Abseil, please complete this form and return to us.

We ask that all participants pay a £25 registration fee and pledge to raise a minimum of £125.

Monies raised from this event can be put towards a fund of your choice. Please write the Fund Code or Department in the space below, if known.

Fund Code/Department……………………………………………………………………..

Personal Details

Full name:

Home Address:

Postcode: Date of birth

Mobile: Email:

Please tick if you are happy for us to contact you by e-mail. We would also like to send you newsletters. This helps reduce our costs

Occupation: Company:

Does your place of work provide matched giving for the sponsorship you raise? Yes No

(If you’re not sure, please ask as it can significantly boost your fundraising income)

Emergency Contact Name and Relationship:

Emergency Contact Telephone Number:

Entry information

You will be given a timeslot in which your Abseil will take place, please tick below which time you would prefer. (Please note that we cannot guarantee a time slot but will do our best to fulfil your wishes)

You will need to arrive 1 hour before your timeslot for some training, health and safety briefings

10am - 11am LIMITED SPACES

11am - 12pm LIMITED SPACES

12pm - 1pm FULLY BOOKED

2pm - 3pm LIMITED SPACES

3pm - 4pm

4pm - 5pm

Fundraising plans

We ask that our participants pledge to raise at least £125. Please detail below how you plan to raise the money listing more than one method.

We ask that participants wear a St George’s Hospital Charity t-shirtwhilst completing the Abseil. If you would be happy to do so then please let us know your size below.

Please state which you would prefer and your size

T-shirt Size: XS S M L XL XXL (please circle one)

I agree for my photograph or story to be used for publicity purposes Yes No

Declaration

  • I understand that if I am accepted to take part in the AbseilI am undertaking a pledge to raise a minimum amount of £125 to be collected by Friday 20thOctober 2017.
  • I declare that I will be over the age of 18 on the date of the Abseil, or over aged 14 and will have a parent/legal guardian with me
  • I declare that to the best of my knowledge I am in a good state of health and take full responsibility for myself
  • I understand that I am participating at my own risk and that any insurance policies I hold enable me to take part

Signature ______

Date ______

What happens next?

Please make sure we get your completed form byFriday 25th August 2017.

Please return this form to the Fundraising Office, St George’s Hospital Charity,

St George’s Hospital, Blackshaw Road, London, SW17 0QT

Or

Email a scanned copy to:

St George’s Hospital Charity (registered charity number 1171195)

Martyn WillisChief Executive, Anna WalkerChair of the Trustees

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