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ENTRY FORM

  
  Supporting

  
  PLEASE HELP - FUNDS FOR
HEART FAILURE & CANCER REHABILITATION RESEARCH		    
 

Name of Centre you wish to participate at
Town/City

PLEASE COMPLETE ALL FIELDS, BELOW

Surname (Last Name)
First Name in Full
Email Address
Address 1
Address 2
Town
County
Country
Postcode
Daytime Telephone
Age and DOB if under 16
Your details will not be given to any third party

Which challenges would you like to participate in?
(You can select as many as you like)

Swimming   Running   Cycling
Walking   Nordic Walking   Dancing   Hula Hooping

Can you help? (Details could be used for publicity). Please give details of any interesting personal items or anecdotes about yourself, or why you are entering Exercise4Life.

If you are having difficulties with this form please call +44 (0) 1382 451146


  • Send money through virginmoneygiving.com
  • Or send a cheque or postal order made payable to WRIGHT Foundation Research, along with your sponsorship form to PO BOX 159, Dundee, DD1 9HF, UK.
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