Fundraising Registration form

First Name

Surname

Address

Address 2

City/Town

Postcode

Contact telephone number

Reason for supporting myheart/ CRY

Name of the event

Date of event

Type and details of event

Venue name

How many people do you anticipate attending / taking part in this event?

Is this event in memory of someone?

Yes No

Please state your relationship to the deceased

Has a memorial fund for this person been set up?

Yes No Unsure

Would you like your fundraising tobe allocated to a myheart fund?

Yes No Unsure

If this is a Corporate, Organisation or Club event, please give details - e.g. name of the company, club, etc

Do you anticipate this being a regular or annual event?

Yes No Unsure

Is this the first fundraising event you have organised on behalf of myheart/CRY?

Yes No Unsure

Collection Pots

Collection Pot Security Seal

Bucket Security (Please note we are unable to provide collection buckets)

Bucket A5 CRY Logo Sticker (Please note we are unable to provide collection buckets)

Poster Pack (Contains 6 A3 CRY awareness posters)

Banner (10'X1') (to borrow)

1st Free T-shirt

2nd Free T-shirt

Please select which of the following other items you require

General Leaflets Heart Screening Booklets Gift Aid envelopes Sponsor Forms#Small round CRY logo stickers A5 CRY logo stickers for collection buckets (please note: we are unable to provide collection buckets)

Any other request or help you require for your event?

Declaration - I understand that I should seek medical advice from my GP if I am in any doubt about my physical ability to take part in this event. I acknowledge that I am undertaking this activity at my own risk and that CRY (Cardiac Risk in the Young) shall not be liable in any loss or injury that might occur as a result of participating in this event, nor any claim arising from this event. I agree to pay all proceeds of the event to CRY within 3 months of each event taking place, even if more events are being planned for the future,and if any expenses have been deducted from the amount raised, details will be provided when paying the money to CRY. I understand that this information will be kept on file in the CRY office. I also agree that I will not engage in activities that will bring the charity CRY or its representatives into disrepute.

I am over 16

If you are under 16 years of age, please have a parent or guardian read and print their name here to show that they have consented to this activity taking place.

Would you like to sign-up to receive either or both of our regular communications?

Enewsletter (monthly) Update magazine (three issues per year)