Bupa Great North Run Application Form 2012

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    Alzheimers Society Application Form Bupa Great North Run 201216 September 2012

    To apply for one of the Alzheimers Societys guaranteed places in the Bupa Great North Run on Sunday 16September 2012 please complete all sections of this form in BLOCK capitals.

    Please note places are allocated on a first come first served basis so please return your form as soon aspossible.

    If you have already secured a place in this event directly from the race organisers, you do not need to fill in thisform please call us instead on 0870 417 0192 to join the team and use your place to raise funds forAlzheimers Society.

    Personal details

    Title__Miss_______Forenames___Melanie_____________________Surname____Davies___________________

    Address 27 Zetland Hunt, Newton Aycliffe, Co. Durham_______Postcode__DL5 7LQ_________Date of Birth 14/09/1982

    Mobile_________________________Email_________________________________________

    Home telephone ____________________Daytime contact number_______________________

    Occupation ___________________________Company________________________________

    Links with Alzheimer's Society

    Are you:

    A person with dementia A friend or relative of a person with dementia

    A professional working in the field of dementia

    How did you find out about running in the Bupa Great North Run for Alzheimers Society?

    Alzheimers Society website Alzheimers Society mailing Alzheimers Society e-mail

    Great Run website Great Run e-mail

    Website / search engine (please specify____________________________)

    Magazine or newspaper advert/article (please specify ______________________)

    Alzheimers Society flyer (please specify where you saw the flyer __________________)

    Word of mouth Other (please specify_______________________)

    If you heard about this run from an Alzheimers Society community fundraiser or local Alzheimer's Society officeplease specify the name of the person or the office

    ____________________________________________________________________________

    Practical details

    FOR OFFICE USE ONLY: Guaranteed Place No:

    Confirmation E-mail Date Initial

    Progress Date Initial

    Payment taken Date Initial

    Cheque banked Date Initial

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    How long, in minutes, do you think it will take you to finish the Bupa Great North Run: _________ minutes

    Running top; We will provide you with a free Alzheimers Society running T-shirt or vest (both made frombreathable material). Please indicate your preference and which size you would like:

    Male

    T-shirt Vest

    Small (38 chest) Medium (40 chest) Large (42 chest) X-Large (44 chest) XX-Large (46

    chest)

    Female

    T-shirt Vest

    Size 10 Size 12 Size 14 Size 16 Size 18

    If you receive a place then we will send you iron-on letters just before race day so that you can display yourname/nickname on your running t-shirt/vest. Please spell out the name you would like to use: (8 lettersmaximum)

    _____/_____/_____/_____/_____/_____/_____/_____

    Press stories

    Why do you want to raise funds for Alzheimers Society? Please tell us your story.____________________________________________________________________________

    ____________________________________________________________________________

    Are you happy to be contacted by a member of our press team? Yes NoIf you are fundraising in memory of someone special, would you like to find out more about setting up a TributeFund in their honour?

    Yes No

    Data Protection

    Alzheimer's Society will not pass your details on to any other organisation. We will use the information you havesupplied to communicate with you in line with the Data Protection Act 1998 and may contact you in the futureabout fundraising opportunities or news we think will be of interest to you.

    Please tick this box if you do not wish to receive contact from us in the future(please note: we will contact you regarding your Bupa Great North Run application)

    Please complete and sign:

    I am registering to run the Bupa Great North Run 2012. I pledge to raise a minimum of 375 for AlzheimersSociety in addition to my registration fee.

    Signed__________________________________________ Date _____/_____/______

    Next steps1. Please email your completed application form to events@alzheimers.org.uk or post it to:

    Events Team, Alzheimers Society

    Devon House58 St Katharines WayLondonE1W 1JX.

    2. A member of the Alzheimers Society events team will contact you to confirm your place, and withinstructions on how to complete the registration process. If you have not heard from us within 1 week

    mailto:events@alzheimers.org.ukmailto:events@alzheimers.org.uk
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    of sending your form please call the events team on 0207 423 5102 or emailevents@alzheimers.org.uk

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    Paying your registration fee

    Please tick one of the following:

    Cheque made payable to Alzheimer's Society of 46 sent with application form

    Credit Card payment

    We do not accept American Express, Diners, Solo or RBS Highline cards

    Name as it appears on card . Issue No.

    Card No.Start DateExpiry Date..

    Signed Date

    mailto:events@alzheimers.org.ukmailto:events@alzheimers.org.uk