Your details Title First name * Last name * Your email address * Your phone number * Your address Postcode * lookup or enter your address manually Organisation name Address * Address line 2 Address line 3 Town or city * Postcode Country Which event are you taking part in? * Event date Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20172018201920202021 Have you registered to take part with the event organisers? * Yes No Fundraising target £ Do you have an online sponsorship page? If so, please enter the link: How did you hear about Epilepsy Action? Is there a special reason for taking part in this event? (e.g. is it in memory of someone special?) 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 Which size would you prefer? Extra Small Small Medium Large Extra large TandC * I agree to the terms and conditions 18 or over I am 18 or over If you are under 18 we require your parent or guardian's consent for you to take part in or organise a fundraising event in aid of Epilepsy Action. If you are under 18 please have your parent or guardian complete this form. Parent or guardian's name if you are under 18 We would like to keep you up-to-date about our work. Please tick how you would like to hear from us. * Email Text Phone None of these methods What would you like to hear about? * Ways Epilepsy Action can support me Ways I can help people affected by epilepsy Opt out of post: Post - We would also like to write to you. Please tick if you'd prefer not to get post from us. 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 8810 or emailing supportercare@epilepsy.org.ukEpilepsy Action privacy policy Leave this field blank
