Sign up for a charity event place

Title *

First name *

Last name *

Email *

Phone *

Mobile

Address *

Address two

Address three

Town/City *

County *

Postcode *

Date of Birth

Which event will you be taking part in? *

Date of event

I pledge to raise the specified minimum sponsorship target *

Why have you decided to support the Macular Society? *

What top type and size would you like? *

Where did you hear about this event?

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 *