Your details Name * Address * Postcode * Email Telephone Mobile How did you hear about Epilepsy Action? Is there a special reason for taking part in this event? Your chosen event Which event are you taking part in? * Event date * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year2019202020212022 Have you registered to take part with the event organisers? Yes If you do not have your own place, please register with the event organisers before completing this form. Fundraising target £ Do you have an online sponsorship page? If so, please enter the link: 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. Which would you prefer? T-shirt Running vest Cycling jersey What size t-shirt? Small Medium Large Extra large What size running vest? Extra Small (34 inch) Small (36 inch) Medium (38 inch) Large (40 inch) Extra Large (42 inch) XX Large (44 inch) What size cycling jersey? XX Small (36 inch) Small (38 inch) Medium (40 inch) Large (42 inch) X Large (44 inch) XX Large (46 inch) Terms and conditions * I agree to the 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 any photographs of people and understand that any photographs forwarded to Epilepsy Action may be used by the charity. I am 18 or over * I am 18 or over If you are under 18, please ask your parent or guardian to read and consent to the terms and conditions above before entering their name below. Parent or guardian's name if you are under 18 Epilepsy Action changes lives – thanks to people like you.We would like to keep you up to date about our work and need your permission to do so.What would you like to hear about? Epilepsy news, information, events, campaigns and research opportunities * Yes No Ways Epilepsy Action can help you (services, products and membership) * Yes No Ways you can raise funds or donate * Yes No How would you like to hear from us? How would you like to hear from us? Email Text Post Phone Please tick one or more optionsThe details you provide will only be used by Epilepsy Action and its trading company (or those working on our behalf). Epilepsy Action will never swap, share or sell your details.For more information about how we use and protect your data visit epilepsy.org.uk/privacyTo update your preferences, please contact our supporter care team on 0113 210 8800 or visit epilepsy.org.uk/contactEpilepsy Action privacy policy Leave this field blank
