CONTACT US REGISTRATION

Walk to Cure Diabetes 2011, online registration

Please complete the form below to register online. All fields marked with * are mandatory and MUST be completed.

Walk/Run Details
Please select the Walk/Run you are taking part in:*

Please note: This walk is being organised by a third party in aid of JDRF and not directly by JDRF


Your Details
Title:*
First name:*
Surname:*
Address:*

Town:*
County:*
Postcode:*
Home phone:
(STD Code)  
Work phone:
(STD Code)  
E-mail address:
Date of birth:
  
I am interested in diabetes because:
JDRF will hold the information about your interest in diabetes on our database. It will not be used externally. If you do not want these details to be used in this way please tick the box.

Family Details
Please provide names of any other family members living at the same address who are also participating. If they are under 18 please provide their date of birth.

Will you be participating as part of a team?*
 Yes
 No (I'm participating as an individual).

Team Details
Team category:*
Organisation:
(if applicable)
Team name:
Are you the team captain Yes No
Captain's first name:
Captain's surname:
Do you require a fundraising pack (sponsorship forms, posters and fundraising guide) to be sent out to you?
 Yes - I would like a pack to be posted out
 No - I can do all my fundraising online

Privacy & Other Information

Please note: Any details given will be passed onto the organisers of this event.

Any information you provide is covered by the 1998 Data Protection Act.

How did you hear about us:
Other - please specify:
 
 I am happy for JDRF to contact me by e-mail
 
From time to time we may send you information on activities of the charity. If you prefer not to receive this information please tick the box below.

Waiver

WAIVER: Except for death and personal injury resulting from the negligence of Juvenile Diabetes Research Foundation or its personnel, I hearby waive any claims against Juvenile Diabetes Research Foundation and its personnel for any injury, loss or damage to person or property, which I suffer participating in this event or any on site activity.

I attest that I am physically fit and able to participate in this event. Where I have had any concerns whatsoever about my physical fitness or health I have consulted my doctor, who has not advised me against participating.

I grant full permission for organisers to film and take photographs of me and to use, in a reasonable manner and context, any film footage, photographs and quotations from me in future marketing material and promotions of this event and Juvenile Diabetes Research Foundation.
 

 Please tick to confirm that you have read and understood the waiver outlined above.