Personal Information

Date of Birth (DD/MM/YYYY)
Country*
State / Province*
Address*
City*
*
*
*
*
*
*
Email*
Confirm Email*
Mobile*
Social Media e.g. Facebook / Twitter

In case of emergency .....

Emergency Contact Name*
Emergency Contact Phone*
Relationship
Your medical conditions or allergies *
Your current medications*

Declaration

All entrants must take responsibility for their own health. If you have any medical conditions or concerns about taking part, please consult your doctor before sending in your entry form.

 

By completing and submitting this Entry Form you are declaring yourself medically fit to compete with no known medical disability that will endanger yourself or others participating in the event. You accept that you enter at your own risk and that the event organisers and/or venue owners will in no way be held responsible for any injury before, during or after the event or for any property damaged or lost. All participants under 16 years of age must be registered by a responsible parent, guardian or carer and accompanied at all times during the event.

Data Protection

By completing this entry form you consent to ACLT securely holding your personal details on our database to contact you via email or telephone for the purpose of managing your participation in the event. ACLT will also contact you on occasion via email, letter or telephone to update on our work e.g. donor registration, patient appeals, fundraising, volunteering. You can opt out of communications at any time by calling 0203 757 7700 or by email to info@aclt.org

Please confirm your consent for ACLT to contact you via email, post, telephone or SMS*
  • Email
  • Telephone
  • Post
  • SMS

Additional Comments

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