Please note: If you wish to split your fundraising income with an Epilepsy Action branch or an alternative charity please contact us and request a joint charity agreement form. Name * Address * Postcode * Telephone Mobile Send me text updates on the work of Epilepsy Action and its trading company No thanks Email Send me email updates on the work of Epilepsy Action and its trading company No thanks Twitter ID Nature of event Date of event Is your event in memory of somebody? If so, who? Fundraising target £ Online sponsorship page details (if any): Epilepsy Action branch member (if so please state which branch): I am over 16 If you are under 16 we require your parent or guardian’s consent for you to take part in an event in aid of Epilepsy Action. If you are under 16 please have your parent or guardian complete this form. I agree Epilepsy Action has been fully informed of the nature and date of the fundraising event. I agree to keep Epilepsy Action fully informed of any changes made to the details provided. All money raised will be in aid of Epilepsy Action. As an independent supporter raising funds in aid of Epilepsy Action I understand that I am liable for any costs or risks that arise. I agree that any photographs forwarded to Epilepsy Action by me may be used in printed material and on our website. I have asked people’s permission before taking any photographs. All funds raised should be sent to Epilepsy Action within six weeks of collection. I understand that I can not deduct costs of the event from the money raised/collected, unless approval has been gained in advance. We would really like to keep you up to date with the work of Epilepsy Action and other ways you can support it, including through our trading company. If you prefer not to be contacted in any of these ways, please tick the boxes below No mail No telephone We will not share your details with anyone else Epilepsy Action privacy policy