Ben Nevis Challenge Registration Form 09 05 12 FINAL - QEF

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