Registration Form 2021
Name
*
First Name
Last Name
Email Address
*
Please note all our return correspondence to you will be via e-mail, and you will receive an e-mail copy of your completed form.
Address
*
Address Line 1
Address Line 2
Town / City
County
Postcode
Phone Number
*
-
Your age on 26/6/21 (necessary for race category)
*
For the purposes of the race category, please tell us your gender
*
Female
Male
There are two registration payment options; you can either pay a £10 registration fee when submitting this form, or alternatively pledge to fund-raise £100 for The Bridgend Centre via our Just Giving page. Please let us know which you agree to:
*
I agree to pay a £10 registration fee with this form, or
I pledge to fund-raise £100 for The Bridgend Centre via Just Giving
Option 1: Race Registration Fee
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( X )
Pay Registration Fee
Race registration fee for one entrant, payable via Paypal / Debit / Credit Card
£
10.00
GBP
Option 2: Fundraising via Just Giving
Please click the image to open and publish your fundraising page
If you have this set-up, please let us know your Just Giving fundraising page address
Please note you can let us know by e-mail at a later date, and we will list your page in our publicity.
Is there any additional information you'd like us to know?
Terms and Conditions
*
Would you like to receive regular updates by email about the Bridgend Centre and the work we do in Bollington?
*
Yes
No
Submit
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