Team or Individual Registration

Team Name

Organisation (if applicable)

Telephone Number *

Mobile phone Number

Address *

50% of my sponsorship money to go to:

Preferred Start time 8.30am 9.15am 10.00am 11.00am

How many other team members? * 1 2 3 4 5 6 0 - just myself Unsure

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? * Yes No

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 * Heart Problems Fainting spells Pain in chest when exercising High or low blood pressure Joint Problems Epilepsy Back complaints Are you on any medication? Breathing difficulties/ asthma Other None

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: *

Disclaimer * 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.

Age Requirements * 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

£ Donation Amount:

Select Payment Method

PayPal

Personal Info

First Name *

Last Name

Email Address *

Donation Total: £5.00