Do something amazing and sign up to our Cycle Challenge today! "*" indicates required fields Step 1 of 2 0% Unique ID Your details... Title* Mr Mrs Miss Ms Dr First name*Surname*Email* Mobile number*Are you over 18?* Yes No Date of birthDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Responsible adult taking part with you*Your address... Please enter your postcode and select your address*Address line 1*Address line 2Address line 3City / Town*CountyPostcode*This field is hidden when viewing the formCountry*Your Cycle... Take advantage of our Early Bird Discount before it ends!*All routes have a suggested fundraising target of £100 50KM - £30 100KM - £35 100 Mile - £40 This field is hidden when viewing the formPlease select your routeAll routes have a suggested fundraising target of £100 50KM - £35 100KM - £40 100 Mile - £45 Are you taking part as a business or organisation? (optional) Yes No Please let us know your business or organisation name*Team name or club (optional)This is optional and you can always email us at a later date if you're not sure of your team or club name right now.Emergency contact name*Emergency contact number* Raise or donate £100 to receive an exclusive Full Zip Cycle Jersey... Your registration fee helps cover the cost of this event but we rely on your sponsorship and donations to reach our £55,000 target... How are you going to fundraise for this event to help us reach our £55,000 target?* I pledge £100 and would like to receive an exclusive Cycle Jersey I will raise as much as I can and create a JustGiving page I'm going to donate in lieu of sponsorship further down on this form Please select your jersey size*For a full size guide on Male and Female jerseys please click here. S M L XL XXL XXXL XXXXL Please let us know your jersey size. If you raise over £100 in sponsorship, you’ll receive a jersey as a thank you. Knowing your size in advance helps us arrange this in the most cost-efficient way for MytonFor a full size guide on Male and Female jerseys please click here. S M L XL XXL XXXL XXXXL Do you wish to buy a Myton Water Bottle for your cycle?* Yes (£2.50) No Is your payment information the same as your participant details entered above?* Yes No First name on Debit or Credit Card*Surname on Debit or Credit Card*Address line 1*Address line 2City / Town*Postcode* Where did you hear about this event?*You can select multiple Email Facebook Flyer Friends, family or word of mouth Instagram Lamp post sign Newspaper / Magazine Myton shop Myton's website Other website Poster Roadside banner Twitter Other Please specify where*Why are you supporting Myton?*You can select multiple In memory Thanks for care Hospice movement Local charity Other Please let us know the first name of your loved one*Please let us know the surname of your loved one*Please let us know their relationship to you*Why are you supporting Myton?*Find out the difference your support makes... Thank you for supporting The Myton Hospices so we can continue to provide our services free of charge to people, and their families, living with terminal illnesses. We may keep in touch with you by post and phone to tell you more about our vital work and other ways you can help, including opportunities to donate, fundraise or volunteer and how your support has made a difference. Please let us know if you’re also happy to hear from us by email and text: By email* Yes No By text* Yes No Like all hospices, we are deeply concerned about the current funding crisis for our services. With costs at an all-time high, we need your support now more than ever to continue providing our care free of charge to patients and their loved ones.. Do you wish to make an optional donation? Donations of £100 or more will receive this year's exclusive cycle jersey!Your donation £41 - donate £1 for every year we have been providing care £56 could fund the cost of two hour’s specialist nursing care £78 will fund one adult counselling session £106 could fund a Respite bed for half a day £156 will fund a patient to attend physio/occupational therapy sessions £300 will fund 10 children’s bereavement counselling sessions £450 will fund an Inpatient bed for one day £1,064 could fund the cost of one week of specialist nursing care A gift of my choice No thank you Please enter your amount*If you have selected a donation by mistake enter 0 if you do not wish to donate. I wish to Gift Aid my donation and increase its worth by 25% at no cost to me I am a UK tax payer and confirm I will pay an amount of UK income tax or Capital Gains tax for each year that is at least equal to the amount of Gift Aid that all charities that I donate to will reclaim on my behalf. I understand that if I pay less Income Tax/Capital Gains Tax in any tax year than the amount claimed on my donations, it will be my responsibility to pay any difference back.Please select the appropriate statement* Yes claim Gift Aid for the last four years /and any I may make in the future, until I notify you otherwise Yes claim Gift Aid for my latest donation /and any I may make in the future, until I notify you otherwise I am NOT a UK taxpayer or do not wish to Gift Aid my donations Event Registrations T&C's... Contact details provided (including email address and telephone number) are used to keep you up to date about the event you are taking part in and support you in your fundraising efforts where appropriate We may ask for next of kin details in case of an emergency. All details will be stored securely and are used in relation to the event you are taking part in. Please ensure that you are physically in person with any team members you sign up to this event and have full consent to share their details with us. If you are not their registration may be invalid. Also, please ensure that you read a full copy of our terms and conditions for this event by clicking here. Your privacy... We promise to do our best to keep your details safe and secure and will only process your data in accordance with the current Data Protection legislation. Our Privacy Policy explains how we keep this promise and you can read more online at www.mytonhospice.org/privacy-policy If you change your mind about hearing from us please email DSCT@mytonhospice.org or call us on 01926 358383. I have read and accept The Myton Hospices Terms and Conditions for this event* I accept I have read and accept The Myton Hospices Privacy Policy* I accept Total This field is hidden when viewing the formDONATIONThis field is hidden when viewing the formROUTEPRICEEBThis field is hidden when viewing the formROUTEPRICEGENThis field is hidden when viewing the formWATER-BOTTLE
