Register for a National Tea Break fundraising pack

If you would like to take part in this year's National Tea Break, please fill in this form. On receipt of your application, we will register you for the event and you will receive an organiser's pack 6-8 weeks before the event.

Contact details

Name: *

Address: *

Postcode: *

Email: *

Email updates:

I would like to receive email updates on the work of Epilepsy Action and its trading company

Telephone number: *

Text updates:

I would like to receive text message updates on the work of Epilepsy Action and its trading company

Mobile number:

How did you hear about National Tea Break?: *

Do you have a specific reason for hosting a National Tea Break?: *

Are you a member of an Epilepsy Action Branch?: *

Yes

If so, which Branch?:

Date of Tea Break if not Friday 19 October:

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 above. We will not share your information with anyone else.

Data protection:

No mail

No telephone

Epilepsy Action privacy policy

Register for a National Tea Break fundraising pack

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