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Title *

First name *

Last name *

Email *

Phone

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Postcode :

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Address*:

Address one *:

Address two:

Town/City *:

County *:

Date of Birth

Which event will you be taking part in? *

Date of event

I pledge to raise the specified minimum sponsorship target *

Where did you hear about this event?

What top type and size would you like? *

I understand I should seek medical advice from my GP if I am in any doubt as to my physical ability to take part in this event *

I confirm that I am taking part in this activity entirely at my own risk and that the Macular Society shall not be liable for any injury or loss that might occur as a result of my participation *

Why have you decided to support the Macular Society?

Would you be happy for our communications team to contact you about your event?

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