Event Date: Saturday 12 December 2015

County: Staffordshire

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 Chase Leisure Centre, WS11 4AL at 11am and finishing at the bandstand with refreshments at Bank Bar & lounge. Come along and walk or jog the route in a Santa suit! 

All we ask is that you raise a minimum of £20 sponsorship and children under 16 are £1 (payable on the day when you register). We will be providing a Santa hat to children on the day. 

Newlife is the UK's leading children's disability charity specialising in support for children affected by disability whether inborn or acquired. In addition to funding the provision of specilaist equipment and research, the charity also offers specially trained nurse support services. It campaigns to ensure children are provided with 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: 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:  0800 988 4640 (Free from UK mobiles & landlines) or Email: fundraise@newlifecharity.co.uk

The Dash will also be supported by Cannock Radio on the day.

To take part please fill in your details below:



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:
Child(ren's) Name(s), Age(s) under 16

Agreement
  Sponsored Walk
  Sponsored Run

I agree to raise £20 sponsorship. 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 Foundation storing and processing data contained on this form.

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

Terms and conditions of entry

Terms and conditions of entry


 



  1. All participants are expected to raise a minimum of £20 sponsorship for Newlife Foundation. 

  2. Your place cannot be transferred to another entrant or deferred to next year.

  3. Dogs are permitted but must remain on a lead.

  4. Sensible footwear must be worn and care taken on route.

  5. The route crosses public highways and all participants must adhere to the Highway Code.

  6. The course is multi-terrain, including roads, fields, and footpaths.

  7. One Santa suit will be provided per entrant.

  8. A free Santa hat will be provided to children under the age of 16.

  9. If you have a medical condition that could be affected by exercise, please obtain your doctor’s approval before participation.

  10. You enter the ‘Dash’ at your own risk and will not take part unless medically fit to run/walk one mile and complete the distance within one hour.

  11. We reserve the right to withdraw marshalling for any participants who take over one hour to complete the course.

  12. While all reasonable action has been taken by Newlife Foundation to ensure the safety of participants, Newlife Foundation cannot be held accountable for any injury, loss or damage sustained during this event.

  13. Newlife Foundation may take photographs of the event and use them in publicity material including on its website. If you do not want your photograph to be used, please contact the Newlife Foundation Fundraising Team.

  14. Newlife Foundation reserves the right to cancel, postpone or change the format of the Santa Dash where this may become necessary due to circumstances out of our control.


 


Please tick to confirm you have read and agree with the terms and conditions.

 

 

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