NB: Please Ensure You Read and Sign the Terms & Conditions Over Leaf Before Submitting

Runner Registration Form Age UK Exeter 2018 10K 18/03/18

Title: Mr / Mrs / Ms /Miss/Dr/ other First Name: Last Name: Address: Date of birth: Gender: Male / Female Telephone Number: Postcode: Email: Are you part of a running club? YES / NO If yes which one?

Please tell us how you heard Are you entering as part Entry Type / Payment about this race – tick below of a Team? Y / N Radio Exe If yes please give the Early Bird Prices for entries Express and Echo name of the team / until received by 31/12/17 Sauce magazine company UKA Affiliated entry £17.95 Other magazine Non Affiliated entry £19.95 Twitter Facebook Entries received after 1/1/18 Browsing on internet UKA Affiliated entry £22.95 Email from Age UK Exeter Non Affiliated entry £24.95 Flyer Running Club You may apply for a UKA Affiliated Running Website place if you are a member of UK Poster Athletics. You must supply your Word of Mouth UKA number below: Full on Sport Other (please state): UKA Membership number:

You may be asked for proof of affiliation at any time.

Please make cheques payable to ‘Age UK Exeter’ and return form and payment to Jacqui Cornish, Age UK Exeter, 138 Cowick Street, Exeter EX4 1HS.

Emergency Contact Details Name of emergency contact Emergency contact’s phone number:

NB: Please ensure you read and sign the Terms & Conditions over leaf before submitting your entry.

Fundraising Every year Age UK Exeter helps and supports over 5,000 older people and their families in the city. We help people living with dementia, people who are lonely and isolated and people who have no one to turn to.

While we appreciate its not always easy to raise sponsorship, we hope you understand that the money raised at this event is essential if we are to continue to support our most vulnerable older people. The people we support could be your neighbour, your parent, your partner or even you.

Please help us by raising sponsorship or making a donation.

Please visit our events page on our website and click on the run icon for more information about fundraising http://www.ageuk.org.uk/exeter/events/

Terms & Conditions:

I agree to abide by UK Athletics rules and accept that this event is potentially hazardous. I am medically fit to participate in the event and understand that I enter at my own risk and that the organisers shall not be held responsible for any injury or illness that may be caused to myself as a result of the event or for any property lost during the race. I also agree to notify the race organisers on 01392 202092 prior to the event if my situation changes. I will write on the reverse of my race number and emergency name and contact details for race day and any medical conditions which the race organisers should be aware of. I agree not to wear headphones during the event, nor will I carry a baby about my person. I understand that the entry fee is non refundable (even if the event is cancelled due to severe weather making the event unsafe or any other unforeseen reason) and that I will compete in my allocated number. If through my non-participation, I pass my number to another runner I will advise the organisers by the submission of an entry form duly completed by my replacement. I hereby give permission for the organisers and their associates to use any recorded materials from this event. The minimum age for this race is 15 years old. I understand that this is an Age UK Exeter event and that by submitting my email, address and contact telephone numbers on this form that site I am agreeing to my information being shared with and stored by Age UK Exeter who may contact me in relation to this and future running events. I understand I can unsubscribe for these communications any time by telephoning 01392 202092 and speaking to Sue Martyr or by emailing [email protected] Age UK Exeter promise not to share your details with any other parties. I understand that Full on Sport will also hold this information for the purposes of chip timing.

Signature: Date: