Your Name First name Surname Email Mobile Date of birth Address Address line 1 Address line 2 City/town Postal code Country - Select -AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorth MacedoniaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Event Date of event Are there any other events that you're interested in? Vest/cycling jersey size - None -XSSMLXLXXL What's your connection to cardiomyopathy? What's your connection to cardiomyopathy? - Select -I have cardiomyopathy or a related conditionI'm a friend/family member of someone with cardiomyopathyI'd like to support the charity in memory of a loved oneI'm a healthcare professionalCardiomyopathy UK is my employer's charityOther… Other We love to get to know our fundraisers so please tell us about yourself and your reasons for supporting Cardiomyopathy UK If you're applying for a Cardiomyopathy UK charity place in an event, are you happy to accept our fundraising target?? Yes I have my own place How much are you hoping to raise and how will you fundraise? Where a registration fee is required, I understand that my place is not confirmed until this has been paid.? Yes Would you be interested in sharing your story to support and inspire others? Yes This could be in our My Life magazine, on social media or as part of one of our campaigns. Would you like to receive email updates from us about the latest support and information for people affected by cardiomyopathy, our campaigns, research and ways to get involved? Yes No If you change your mind, you can unsubscribe at any time by contacting us. We will never sell or share your data with any third parties unless required to do so by law. I understand? We would advise anyone with cardiomyopathy, a related condition*, a device fitted or a hereditary risk of cardiomyopathy or related conditions to speak to their doctor before undertaking any challenge that involves significant physical activity to understand any possible risks and agree that it is safe to go ahead. If you are applying for one of our charity places in an event, please note that Cardiomyopathy UK may be unable to grant you a place if, upon guidance from a cardiologist, we do not feel the intended activity is safe. Please only click 'Submit' once Read our privacy policy