Newlife Annual Santa Dash

Join us on Saturday 17th December 2011

Calling all budding Santas to put their best boot forward to help disabled children with Newlife Foundation at Cannock's annual Santa Dash.

Starting from Cannock Leisure Centre and finishing at South Staffordshire College, come along and walk or jog the route in a very fetching Santa suit!
We will be providing refreshments at the end of the Dash to all those taking part and there will be a brass band to provide entertainment as the Dashers go past.

A minimum of £30 sponsorship per adult is required and children are welcome to come along for free. We will be providing a Santa hat to children on the day and should they wish to make a small donation towards the cost of the hat, this will be gratefully received.

Newlife is the UK's leading children's disability charity specialising in support to aid children affected by all disabilities. In addition to funding equipment grants and research, the charity also offers support services operated by specially trained nurses and campaigns for a fairer deal for children to obtain the essential equipment and services they deserve.

100% NEWLIFE GUARANTEE - ALL FUNDS RAISED WILL HELP CHILDREN IN STAFFORDSHIRE. NOT A PENNY WILL BE TAKEN OUT FOR ANYTHING ELSE. WE'RE ABOUT REAL HELP FOR REAL CHILDREN.

If you would like to create an online sponsorship page, *please sign up at our JustGiving Unique URL: JustGiving Unique URL: http://bit.ly/FundraiseWithJustGiving and follow the steps to 'make a page'.

Questions and queries? Our Fundraising Team are on hand to answers your questions and queries.
Call: Freephone 0800 988 4640 or Email: fundraise@newlifecharity.co.uk

*Data held with JustGiving is not transmitted to Newlife Foundation by any means. Concerns should be directed to the JustGiving Privacy Policy page

To take part please fill in your details below:

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Event Application Form

Please note each entrant must complete the application in full.

 

Personal Details
Full Name:
Address:
Town:
County:
Post Code:
Home Telephone:		Mobile Telephone:
Email:

Agreement

Sponsored Walk    Sponsored Run

I agree to raise a minimum sponsorship depending on status of participation (see below). I am taking part in this event at my own risk and the promoters, or any person(s) involved in organising the event will not be responsible for any injury or illness caused by my participation. I will only take part in the event if I am fit enough to complete the course. By ticking this box I am agreeing to participate in the above event. I am also agreeing to Newlife charity storing and processing data contained on this form.

Categories of Minimum Sponsorship

Please tick the relevant box and note that each individual (corporate or family) will need to fill in a registration form. If you are an adult bringing a child then please tick and complete the form below for each entrant.   Adult - £30   Child (up to 16) - Free

Medical Declaration - This form must be completed in full by all participants
Date of Birth:
Your GP's Details
Doctor's Name:		Telephone Number:
First Emergency Contact
Surname:		Forename:
Relationship
Home Telephone:		Mobile Telephone:
Please state whether you have suffered/are suffering from any of the following:
1. Asthma or any condition affecting the lungs or throat			Yes No
2. Blood pressure, palpitations, shortness of breath, chest pain or any condition of the heart			Yes No
3. Fits, fainting, black-outs or any disease of the nervous system			Yes No
4. Any condition affecting the ears and eyes or any defect of hearing or sight			Yes No
5. Any accident, physical defects, disc, hernia or back trouble			Yes No
6. Complaints or the arm, hand or shoulder caused by strain of muscles, tendons, joints or arthritis			Yes No
7. Allergy to any drugs or specific substances			Yes No
8. Are you currently receiving any medical treatment and/or taking any medication			Yes No
9. Any illness or conditions not already mentioned			Yes No
If you've answered yes to any of the above medical conditions, please give details here:
PLEASE NOTE: If you answer yes to any of the questions above and in any way believe that your ability may be impaired because of it, please seek the advice of your GP. Please confirm that you have sought and received permission from your GP to take part in this event (if relevant)

Disclaimer

Newlife Foundation has taken all reasonable steps to eliminate the chance of injury but there is a certain minimal risk in every activity and you should withdraw from the event if you have any doubts. While public liability insurance is in force, this does not cover personal accidents other than personal injury caused by our negligence. We reserve the right to remove any participant to an event who does not abide by the rules. Other than as described above, Newlife Foundation, its employees, agents and volunteers are under no liability whatsoever to participants or spectators in respect of any loss or personal injury which may be sustained in the course of this event. Newlife Foundation for Disabled Children is registered with the Information Commissioner and is committed to ensuring that all personal information is treated properly in accordance with the Data Protection Act 1998. Newlife Foundation for Disabled Children may use your details to contact you via mail, telephone, fax or electronic communication to send you further information regarding Newlife Foundation. If you have any queries then please contact Pat Grant, Data Controller for Newlife Foundation on 01543 468888 or email pgrant@newlifecharity.co.uk