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Payment
Enclosed fee £27 (please make cheques payable to Zoë’s Place) or please debit my debit/credit card * for £27 ¨
*credit & debit card payments are subject to a 2.5% administration charge
Type of card ____________________________________________________________________
Card Number: ____________/____________/__________Start Date: ________ /________
Expiry Date: _________/_________ Security Code: ____________
Card Holders Name:____________________________________________________________
Card Holders Signature:________________________________________________________
By signing this form I agree to use my best endeavours to raise £300.00, and
that all monies received as a result of the above named event will be donated
directly to Zoë’s Place Middlesbrough. I agree to have all funding from the
above named event paid to Zoë’s Place within eight weeks of the event’s
completion unless otherwise agreed in writing by Zoë’s Place. I am aware that
the £27 registration fee that accompanies this form is non refundable and that
in order to become a fully registered runner for Zoë’s Place that I must
complete both parts of the registration process, the first initial part from Zoë’s
Place Baby Hospice and the second being my application from the online token
registration which will be sent after my registration has been processed.
Print Name: ____________________________________ Date: _________________________
Sign: ___________________________________________________________________________
Please return no later than the 23rd June 2017 to:
Zoë's Place Baby Hospice
Great North Run 2017
Crossbeck House, High Street
Normanby,
Middlesbrough
TS6 9DA
Registered Charity Number 1092545
Tel 01642 457985
ZOË'S PLACE BABY HOSPICE GREAT NORTH RUN 2017
Join over 56,000 runners and take part in the Great North Run: the
worlds biggest half marathon on Sunday 10th September 2017.
If you’re enthusiastic, energetic and would like to participate in one of
the most iconic half marathons on the planet, amidst an electric
atmosphere then this is the event for you!
The route will cover 13.1 miles starting at Newcastle, crossing the Tyne
Bridge then through Gateshead and finishing in South Shields. Each
entrant must be over the age of 17 to participate and use your best
endeavours to raise £300.
It is £27 to register. Registration is quick and easy;
- complete the attached form
- return it to Zoë’s Place with your registration fee of £27
(cheques should be made payable to Zoë’s Place)
- payment will be processed and your sponsorship pack sent
out in the post.
Your registration fee will include sponsorship forms, tips to maximise
your fundraising, a technical t-shirt, information about the charity and
a warm welcome from our fundraising team back at the charity village
after your run!!!
If you have any further questions please call us on
01642 457985 or email [email protected]
Title: ___________ Name: ____________________ Surname: ______________________
Address: ___________________________________________________________________
_____________________________________________ Post Code: ___________________
Home Tel: ________________________ Mobile:_________________________________
Email: ______________________________________________________________________
(you must provide a working email address in order to fully complete your registration)
D.O.B:___________/__________/__________
T-shirt Size: Small Medium Large XL XXL
How Did You Hear About The Great North Run?
Newspaper Great North Run Website Our Website/Facebook
Previously Participated Word Of mouth Twitter
Other (please state) _______________________________________________________
Health Information:
It is important that we are aware of any health problems which may cause you to require medical attention during the run. All Information will remain confidential.
Do you have any ongoing health issues which may affect your ability to participate in the Great North Run 2017?
Yes No (if yes please state) ________________________________________
Are your symptoms controlled by prescribed medication? If so please provide information that a medical professional should be aware of in case of emergency:
______________________________________________________________________________
______________________________________________________________________________