Challenge event registration form

First name

Surname

Mobile

Date of birth

Address

Address line 2

City/town

Postal code

Country

Event you are interested in

Date of your event

Are there any other events that you're interested in?

Vest/cycling jersey size

What's your connection to cardiomyopathy?

Other

Who is affected by cardiomyopathy?

Other

Cardiomyopathy UK is entirely dependent on funds raised by our supporters as we receive no government or NHS funding. We are very grateful to all of our fundraisers, many of whom are personally affected by cardiomyopathy and myocarditis.

The charity has a duty of care for the health and welfare of all of our fundraisers. In this respect, when anyone who is diagnosed with a serious health condition such as cardiomyopathy or myocarditis, or if anyone in your immediate family has cardiomyopathy, and wishes to undertake a challenge event, we kindly ask that they provide us with a written statement of fitness to participate from their cardiologist, dated within 1 year.

Do you have a statement of fitness dated within the last year?

Yes

If you don't have one, our team will guide you through how to get this.

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

We love to get to know our fundraisers so please tell us a bit about yourself and/or your reasons for supporting Cardiomyopathy UK

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

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.

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