Charity Place Application Form

Event: Please Select Great North Run Great North Swim Great Manchester Swim Title: Mr Ms Miss Mrs Dr First name: Surname: Gender: FemaleMale Address:

Town: County: Postcode: Must be correct format eg PY34 4YT - uppercase letters and a space between the 2 parts Telephone number:  -  - Email: Confirm email:   Date of Birth: format dd/mm/yyyy Have you taken part in an event for The Christie before? YesNo Why do you wish to support The Christie?
(Do you have a personal motivation or connection to the hospital?) How do you plan to raise your sponsorship? What will your fundraising target be? £ Does your employer support matched giving? YesNo How did you hear about supporting The Christie at this event?: Please select The Christie website Facebook Twitter Other website Previous Participant Visitor to The Christie Poster/Flyer Banner E-newsletter Successes Magazine Other Christie Mailing Headlines Employer Word of Mouth Bridgfords Estate Agents Newspaper Other I agree to this statement   Yes No

We value your support and promise to respect your privacy. The data we gather and hold is managed in accordance with the Data Protection Act (1998). We will not disclose or share personal information supplied by you with any third party organisations. By giving us your details you are agreeing for us to contact you about our work and other fundraising activities.

If you are happy for us to do so please tick this box.

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