Just Walk - Application for a Guaranteed Place

WellChild’s Privacy and Data Protection Policy can be viewed here

* denotes required field. * What distance are you applying for? 60km 40km 20km 10km * Title  Mr Mrs Miss Ms Dr Rev Other  Other  * First name  * Last name  * Date of birth  (dd/mm/yy) * Email address  * Confirm email address  * Contact telephone number  * Address line 1  Address line 2  Address line 3  * City / Town  County  * Country  * Post code  * Please state your t-shirt size  Small Medium Large Extra Large Occupation  Employer  * Do you have a medical condition  about which the organisers  should be informed?  Yes No If yes, please give details  * Do you have any dietary requirements eg. Vegetarian?    * The minimum fundraising targets are £200 (60km) and £150 (40km). Bearing in mind these targets what are your fundraising expectations for this event?  £ Will your employer match this amount or any part of it ? Yes No Unsure Where did you hear about WellChild’s involvement in the event? WellChild Website WellChild News/eNewsletter Work Friend Gym Other (please specify) Other: Registration I would like a guaranteed place in Just Walk and agree to raise at least the relevant minimum fundraising target for WellChild. Yes No Don’t forget to Gift Aid it !   If you’re a taxpayer, using Gift Aid means that for every pound you give, WellChild gets an extra 25 pence from the Inland Revenue. Your donation goes further and it doesn’t cost you a thing. I would like WellChild to claim back the tax on any donation I make to WellChild. I declare that I am a taxpayer and I want the charity to treat all donations I make as Gift Aid donations. I understand that I must pay an equal amount of income tax or capital gains tax at least equal to the tax deemed to have been deducted from this donation.    I have read the terms and conditions. I agree that I participate entirely at my own risk and accept that WellChild are not liable for any loss, damage, claim, expense, injury or accidents which may arise as a consequence of my negligence at the event. I will abide the rules of the event and remain responsible for my own property.  I am in good health and will have done sufficient training to safely complete the course.  We would like to keep you informed of the activities of the charity that we feel may be of interest to you. Please tick if you do not wish to receive this.