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BNTVA Fundraising Registration form PERSONAL DETAILS: Title: ………………… Gender (Please tick): � Male � Female First name: …………………………………………….Surname: …………………………………………….. Date of birth: ……………………………………. Email (preferred)…………………………………………………………………………………………………. Email (other) ……………………………………………………………………………………………………… Home address: ……………………………………………………………………………………………………. …………………………………………… Post code: ……………………………… Occupation:……………………………………………………… Company name:………………………………………………… Home Tel: ………………………………………....................... Mobile Tel: ………………………………………………………… Work Tel: ………………………………………………………(only if we can call you at work)

FUNDRAISING: - Have you taken part in a charity fundraising event previously?

� Yes � No If yes, please give details: Date: ……………………………………………………………………………………………………………. Charity / Event: ………………………………………………………………………………………………… Total Raised: ………………………………………………………………………………………………….. Details:………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… - Does your employer operate a matched giving scheme? (i.e. whatever you raise is doubled by your company) �Yes � No � Don’t know but will enquire - Please explain how you plan to raise the minimum fundraising target of [£ ]. Plan carefully and give as much detail as you can as this section plays an important role in our decision to make you our authorised fund raiser. Remember that fundraising is not limited to asking people for sponsorship. (attach an extra sheet for your answer if necessary) I plan to raise [£ ] minimum by:

� Sponsorship from family, friends, colleagues, clients, work, clubs, schools, etc. Details:………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………

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Estimated Total: ………………………………………………………………………………………………..

� Organising my own fundraising events e.g. a quiz night. Details: ………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… Estimated Total: ……………………………………………………………………………………………….

� Other (any other info you feel may aid your application) Details: ………………………………………………………………………………………………………… …………………………………………………………………………………………………………………… Estimated Total: ………………………………………………………………………………………………. Do you think you could raise more than [£ ]? If so, how much:

[£ ] � [£ ] � [£ ] � [£ ] � Other, please specify...................

DATA PROTECTION: We will hold and use the data you have supplied for administrative purposes and to keep you informed of our fundraising and other activities. We hope you will want to stay in touch after the event, but if you would prefer

not to receive further information, please tick this box �

Terms and Conditions

PLEASE READ CAREFULLY

• By signing this application form you are committing to raise a minimum of [£ ] for the charity (excluding Gift Aid) by [DATE]

• BNTVA does not take responsibility for any costs or health issues arising in relation to any of your fundraising activities.

• BNTVA reserves the right to refuse an application at its absolute discretion.

• You must be 18 years or over on the day of the race.

• If you are unable to complete your fundraising activities, all donated monies collected in support of BNTVA must be forwarded to the charity or returned to the individual sponsors. Monies already received by the charity will not be refunded.

• You must contact BNTVA immediately if you think you are going to be unable to complete your fundraising activities.

PLEDGE: I have read and understood the terms and conditions above. I understand that I am undertaking a pledge to raise a minimum of [£ ] (excluding Gift Aid) for BNTVA by ……………[DATE]. Signed: ……………………………………………Dated………………………………………..