Ben Nevis Challenge Registration Form 09 05 12 FINAL - QEF

BEN NEVIS CHALLENGE 2012Saturday 29th—Monday 1st OctoberREGISTRATION FORMBefore registering please read our Terms and Conditions outlined below, if you agree tothese please sign and date the form at the bottomEntry Fee & Fundraising PledgeI would like to apply to take part in the Ben Nevis Challenge 2012 for QEF. I am aware that I willneed to pay a £49 registration fee and complete a pledge confirmation, pledging to raise aminimum of £550 (excluding gift aid) of which 60% is due by the 1st August 2012.I am also aware that I am responsible for arranging my own return transport to the Ben NevisHotel & Leisure Club, Fort William.TITLE SURNAMEFIRST NAMEDate of Birth(yy/mm/year)Home AddressCity/TownPostcodeHome number:Mobile:Work no:*E mail:*Please provide an email address so we can email your challenge information and details to you.*I agree to my email address being given to my fellow challenge participants □ (please tick)(If you would like to talk to other people taking part in the Ben Nevis Challenge about training andfundraising we can pass on your details to others taking part in the trip)Where did you hear about Queen Elizabeth’s Foundation for Disabled People (QEF)?How did you hear about this challenge?Registered Charity No 251051

Would you be happy for us to use your story in PR work to promote the QEF?YesNoWill your employer match or contribute to the amount that you raise?Yes No (if yes please supply their name and address)Have you done any hikes like this before, if so, which ones and how many times?Accommodation—room sharingWe have booked twin and double rooms. If you would like to share a room with a friend pleasestate their name below.Name(s)If you are travelling on your own you will be allocated a twin room share with another participant.If you would like a single room to yourself, there will be a single supplement charge of £15.00 pernight, if you would like your own room please tick the box below:I would like my own room and agree to a £15 supplement per night(please note this subject to availability at the time of booking)T-shirtsWe will provide you with a free QEF T-shirt for your challenge. Please select which size you wouldlike:Small Medium LargeEmergency ContactNameAddress PostcodeRelationship Telephone numberMedical ConditionsDo you have any medical conditions (e.g. epilepsy, diabetes), medical history (e.g. back problems),allergies to any medicines?If so, please outline details here

REGISTRATION FEE PAYMENTCheques can be made payable to ‘Queen Elizabeth’s Foundation’ or fill in your card detailsbelow.(Please note we only accept Mastercard/Visa/Maestro)Visa Mastercard Switch/MaestroCard Number:Name on Card (as it appears on the card):Expiry Date:Start date:Security code (last 3 digits on signature strip):Issue No:(maestro only)Signed DateOR □ I enclose a cheque made payable to ‘Queen Elizabeth’s Foundation’ .DECLARATION & REGISTRATIONI confirm that I have read and agree to QEF’s Ben Nevis Challenge Terms and Conditions.I understand that if any of the information provided by me on this form is found to be false, Irisk losing my place on the Ben Nevis Challenge. By signing this form I agree with the Ben NevisChallenge registration agreement.You must be at least 18 years of age when any booking is made.Children aged 14 years and over are eligible to be registered for the Event, provided they areaccompanied by an adult. The adult to child ratio is 1:1 and we ask that the adult and child bookat the same time.Adult PartcipantI enclose £49 as a registration fee and understand this is non-refundable. I confirm that I amover 18 years old and all of the information provided by me on this form is, to the best of myknowledge, true and correct.Signed:Date:Child ParticipantI enclose £49 as a registration fee and understand this is non-refundable. I confirm that I am theparent/guardian of the child registrant and by signing the registration form I agree to accept theconditions of entry within the terms & conditions on behalf of the child and are responsible forensuring all information supplied is correct.Signed:Date:Thank you so much for taking the time to complete this form.Please return to:Annie Slater, QEF, Leatherhead Court, Woodlands Road, Leatherhead, Surrey, KT22 0BNTel: 01372 841130E-mail: annalisaslater@qef.org.ukWeb: www.qef.org.ukRegistered Charity No 251051