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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 [email protected] 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
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of sending your form please call the events team on 0207 423 5102 or [email protected]
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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:[email protected]:[email protected]