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Sunderland BIG Walk 2014 - ENTRY FORM Walk and We Hope Many More Will Join in This Year

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Sunderland BIG Walk 2014 - ENTRY FORM Walk and We Hope Many More Will Join in This Year Declaration: To my knowledge, myself and the children included on this entry form have no injuries or medical conditions/history that would prevent me/them from participating in this event. If I/they do feel unwell or experience any adverse effects whilst participating, I/they will stop immediately and inform a member of staff. I/they are aware of and understand the potential risks of taking part in the event and are participating in the knowledge of this. Without prejudice Sunderland City Council accepts no liability for loss or damage however arising whilst taking part in this event save loss or damage caused by its negligent act or omission. I understand that photographs and videos will be taken at the event and if I do not wish myself or the children I am bringing to be included in photographs and videos I/they will move out of the camera range. Signature: Name : Date: SUNDERLAND BIG Walk T-shirt can be ordered to wear on the day. Please write in the table below the quantity you would like to order. The dealine for T-shirt orders is Friday 29 August. (Orders after this date cannot be processed. A limited number of T-Shirts will be available for sale at registration on the day). Child £3 Adult £4 Small Large Small Medium Large X-Large XX-Large 28” chest 30” chest 35-37” chest 38-40” chest 41-43” chest 44-46” chest 47-50” chest Payment details: Pay in person: Complete the entry form and pay by cash, cheque or credit/debit card at: • Sunderland Aquatic Centre • Silksworth Community Pool, Tennis and Wellness Centre • Washington Leisure Centre • Hetton Community Pool and Wellness Centre • Houghton Sports Centre • Seaburn Wellness Centre • Bunnyhill Wellness Centre Pay by post: Complete the entry form and send a cheque for the full amount made payable to Sunderland WALK 2014 City Council or complete the card details below and return the completed form to: Active Sunderland, Civic Centre, Burdon Road, Sunderland, SR2 7DN BIG Sunday 14 September I enclose a cheque for £ made payable to Sunderland City Council or please charge my debit/credit card 10am Card No: - - - Start: National Glass Centre, St Peter’s Riverside Valid From: / Expires End: / Issue No: Finish: Washington Wetlands Centre (6.5 miles) Security Code (last 3 digits from the number on the back of the card): or Herrington Country Park (11.5 miles) Name on card: Registration from 9am More BIG events to come: Signature of Card Holder: Date: For more information please visit www.activesunderland.org.uk BIG Workout: Tuesday 4 November or email [email protected] or call 0191 561 4687 For office use only: Date Received: Date Processed: Processed By: Confirmation email sent: Over 350 people took part in last year’s Active Sunderland BIG Sunderland BIG Walk 2014 - ENTRY FORM Walk and we hope many more will join in this year. The BIG Walk is Walker Details: a wonderful way to be active with your family and friends whilst Please note that one adult may supervise a maximum of four children up to the age of 16. taking in some of the best scenery the city has to offer. You could Contact address: . be sponsored to do the BIG Walk and raise money for the Mayor’s Post Code: . Telephone No: . charities, your favourite charity, sports club or community group? Email (please print clearly): . Walker 1 Name: . This year the BIG walk is supporting the BIG Walk T-shirt Email (if different from above) . Mayor’s charities - Age UK Sunderland, North East NSPCC (Childline Schools Why not buy yourself a BIG Walk T-shirt to Date of Birth . Male Female Service, Sunderland) and Action on wear on the day? Chosen Walk: 6.5 mile 11.5 mile Did you take part in the BIG Walk in 2013? Yes No Dementia - Sunderland and for every Adult T-shirts £4, Please tick this box if you do not wish to receive further information from Sunderland City Council entry, £1 will be donated to the Mayor’s Children’s T-shirts £3 regarding other BIG events and related services charities. Deadline for T-shirt orders is Walker 2 Name: . A great deal of positive feedback was Friday 29 August. A limited number of t- Email (if different from above) . received from last year’s participants - shirts will be available to purchase on the “What a brilliant day, the weather was day at registration at a slightly increased Date of Birth . Male Female great for walking. I loved the route, it was cost of £5 per adult and £4 per child. Chosen Walk: 6.5 mile 11.5 mile Did you take part in the BIG Walk in 2013? Yes No very well marshalled and very well Please tick this box if you do not wish to receive further information from Sunderland City Council organised. Thanks to all the organisers Cost of entry regarding other BIG events and related services and people involved” £5 per adult Walker 3 Name: . £3 per child (12 to 16 yrs) How far is it? FREE for under 12 yrs Email (if different from above) . Date of Birth . Male Female There are two distances to choose from: *Please note that entries will be accepted on the day at registration at a slightly Chosen Walk: 6.5 mile 11.5 mile Did you take part in the BIG Walk in 2013? Yes No Longer walk - increased cost of £6 per adult and £4 per Please tick this box if you do not wish to receive further information from Sunderland City Council is 11.5 miles and finishes at Herrington regarding other BIG events and related services child. Country Park Walker 4 Name: . Shorter walk - Closing date for is 6.5 miles and finishes at Washington pre-event entries Email (if different from above) . Wetlands Centre Friday 5 September 2014 Date of Birth . Male Female Chosen Walk: 6.5 mile 11.5 mile Did you take part in the BIG Walk in 2013? Yes No After the BIG Walk Please tick this box if you do not wish to receive further information from Sunderland City Council All walkers will receive a medal and a regarding other BIG events and related services goody bag upon completion of the BIG Walker 5 Name: . Walk and a shuttle bus will return all walkers to the National Glass Centre. Email (if different from above) . Date of Birth . Male Female For more detailed information Chosen Walk: 6.5 mile 11.5 mile Did you take part in the BIG Walk in 2013? Yes No on the BIG Walk please visit Please tick this box if you do not wish to receive further information from Sunderland City Council www.activesunderland.org.uk regarding other BIG events and related services Please see back page for details of where to send your entry form and how to pay..
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