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Would you like an Epilepsy Action t-shirt, running vest or cycle jersey?

Please only complete this section if you wish to pledge to raise a minimum of £75.We can only provide one free item for each event.

Terms and conditions: Epilepsy Action has been fully informed of the nature and date of my fundraising. I agree to keep Epilepsy Action up to date with any changes made to the details provided. All money raised will be in aid of Epilepsy Action and I agree to send donations within six weeks of collection. 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 I cannot deduct costs of the event from donations, unless approval has been gained from Epilepsy Action in advance. I agree to ask permission before taking and sharing any photographs of people at my event.

If you are under 16 we require your parent or gaurdian's consent for you to take part in or organise a fundraising event in aid of Epilepsy Action. If you are under 16 please have your parent or guardian this form.

Epilepsy Action will never swap, share or sell your details. For more information, read our privacy policy.

You can update your preferences at any time by contacting our supporter care team on 0113 210 8800 or emailing