Fundraising and events registration form - Dudley Group NHS Charity

First Name

Last Name

Address

Address Line 1

Address Line 2

City

County

Postcode

Phone/Mobile

Date of Birth

What is your reason for taking part in this event?

Personal challenge

In memory of someone

I have a connection to the charity

Other, please specify

Please specify

How did you hear about us?

Website

Social media

Friend/Relative

Newspaper

Leaflet/Poster

Staff member

Other

Please specify

If you have a particular reason for taking part, would you be willing to share your story?

Yes

Please indicate below what you’ll need, including quantities, in the table listed below:

Collection tins (please enter quantity below)

Setting up a sponsor page e.g. JustGiving page

Enthuse event page (staff only)

Public collections

Raffle/Tombola

Design of posters (staff only)

Other

Please specify

How many collection tins do you require?

Please note – if you request a bucket/goblet, you must return it to us within three months of your fundraising ending.

Our fundraising is (please tick appropriate to you)

Individual led fundraising (something you are organising yourself).

Fundraising through a company/business.

Fundraising through social/community group.

An event or challenge organised independently or with others. Please give details.

And takes form of:

An organised event I have signed up to (e.g. Birmingham Half Marathon)

Company name

Group name

Name of event

Name of event/challenge

Date and Time of Event/Challenge

Venue

Address

Address Line 1

Address Line 2

City

Postcode

My fundraising goal is £

I understand that I should seek medical advice from my general practitioner if I am in any doubt about my physical ability to take part in this event.

I acknowledge that I am undertaking this activity entirely at my own risk and the Dudley Group NHS Charity shall not be liable in any way for any injury or loss that might occur as a result of my participation.
I understand that the Dudley Group NHS Charity will not be liable for any claim which may arise from this event.
I agree to pay all proceeds of the event to the Dudley Group NHS Charity within 8 weeks of the event taking place.

Don’t forget to check if your employer operates Matched Giving!

Printed name

Date

Parental/Guardian name required (if under the age of 18):

I consent to have this website store my submitted information so they can process my registration. The data you submit here will only be used in relation to your registration. By submitting any registration via this part of the website you are granting us permission to store and process your data. Your information will never be sold on to any third parties.

If you are happy for us to keep in touch with you, please tick the following boxes for acceptable ways to contact you by:

Post

Telephone

Fundraising and events registration

Together we can transform more lives.