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Conditions of Entry
Team or Individual Registration
Organisation (if applicable)
Mobile phone Number
50% of my sponsorship money to go to:
Preferred Start time
How many other team members?
0 - just myself
Have you got a special reason for taking part?
If yes, would you be happy for your story to be used to help publicise the event?
Any special requirements or further space for above questions
Have you had any of the following? Please tick all that apply, consult your doctor for advice and give details below
Pain in chest when exercising
High or low blood pressure
Are you on any medication?
Breathing difficulties/ asthma
Details of medical condition:
Please provide a name and contact number of someone who could be contacted in case of an emergency on the date of event
Emergency Contact Name:
Emergency Contact Phone number:
I have read and understood the conditions of entry and I hereby release both The Rotary Club of Chipping Norton and GLL, its employees and owners, from any claims, demands and causes of action arising from my participation in this event. I fully understand that should I injure myself as a result of this event that I hereby release Rotary and GLL from any liability now or in the future.
I am over 16 years old on date of event
If not, my application is being made by my parent or guardian
Parent / Guardian Name
Registration Fee Explained
£5 per individual, either pay for yourself only or group together and pay together
£5 for an individual
£10 for two people
£15 for three people
£20 for four people
£25 for five people
£30 for six people
£35 for seven people
Give a Custom Amount
Select Payment Method