Name * Address * Postcode Telephone number Mobile number Can we send you text message updates on the work of Epilepsy Action and its trading company Yes No Email address * Can we send you email updates on the work of Epilepsy Action and its trading company Yes No Date of birth * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000 Occupation Employer Does your employer run a matched giving scheme? - None -YesNo Have you run the London Marathon before? - None -YesNo If so, which year(s)? Did you raise money for charity? - None -YesNo If yes, how much? Have you applied for a place through the Virgin London Marathon ballot? - None -YesNo Do you have any fundraising experience? Please explain Where did you hear about running for Epilepsy Action? Why do you want to run for Epilepsy Action? How much do you hope to raise? £ (please note the minimum sponsorship pledge is £1,750) How would you aim to achieve your pledged target? Please give as much detail as possible There are limited places available and completion of this form does not guarantee you a place in the marathon. Once the results of the official entry ballot have been announced in October 2012, we will select our team and contact you if you have been successful in getting one of our Golden Bond places. We would really like to keep you up to date with the work of Epilepsy Action and 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: No mail No mail No telephone No telephone By submitting this form you are agreeing that Epilepsy Action can contact you by telephone, letter or email for any matter relating to your fundraising and participation in this event. You pledge to raise the minimum sponsorship of £1,750. Epilepsy Action privacy policy
