Enclosed fee £27 (please make cheques payable to Zoë

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:

______________________________________________________________________________

______________________________________________________________________________