The Fun 5k

Main applicant*

Adult (£15)
Family Ticket (£45)

Name*

First Last

Email*

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Date of Birth*

Age

Phone*

Emergency contact name & phone number*

Do you have any medical conditions?*

Yes (if yes please provide detail below)
No

Medical conditions (If you answered yes to the question above please list any medical conditions below)

You will be charged the standard Adult registration fee on submission, along with additional registration fees for any additional people you're registering below.

Are you registering more than one person?*

Yes
No

Multiple registrations

If registering more than one person please detail all participants below

Person Two Registration Fee

Adult (£15)
Child under 13 (£10)
Part of Family Ticket

Person Two name

First Last

Person Two Email

Person Two Date of Birth

Person Two Emergency name and contact number

Person Two Medical Conditions

Person Three Registration Fee

Adult (£15)
Child under 13 (£10)
Part of Family Ticket

Person Three name

First Last

Person Three Email

Person Three Date of Birth

Person Three Emergency name and contact number

Person Three Medical Conditions

Person Four Registration Fee

Adult (£15)
Child under 13 (£10)
Part of Family Ticket

Person Four name

First Last

Person Four Email

Person Four Date of Birth

Person Four Emergency name and contact number

Person Four Medical Conditions

Person Five Registration Fee

Adult (£15)
Child under 13 (£10)

Person Five name

First Last

Person Five Email

Person Five Date of Birth

Person Five Emergency name and contact number

Person Five Medical Conditions

Person Six Registration Fee

Adult (£15)
Child under 13 (£10)

Person Six name

First Last

Person Six Email

Person Six Date of Birth

Person Six Emergency name and contact number

Person Six Medical Conditions

Please Note

For large bookings, please do an additional booking form and email sarah.cherry@ydh.nhs.uk with the names of your members to ensure you are all together

Please choose your preferred start time*

10:00 am
10:30 am
11:00 am

If you prefer to raise for a different department at Yeovil Hospital please list it here

Do you have a special reason for taking part in this event?

Can we use your story to publicise our event?*

Yes
No

How did you hear about this event?*

Facebook
Western Gazette
Hospital

Merchandise available to purchase for the event

Adult T-shirt SMALL

Price: £ 12.00 Quantity:

(£15 on event day)

Adult T-shirt MEDIUM

Price: £ 12.00 Quantity:

(£15 on event day)

Adult T-shirt LARGE

Price: £ 12.00 Quantity:

(£15 on event day)

Adult T-shirt X-LARGE

Price: £ 12.00 Quantity:

(£15 on event day)

Adult T-shirt XX-LARGE

Price: £ 12.00 Quantity:

(£15 on event day)

Child T-shirt 6-7yr

Price: £ 8.00 Quantity:

(£11 on event day)

Child T-shirt 8-10yr

Price: £ 8.00 Quantity:

(£11 on event day)

Child T-Shirt 10-13yr

Price: £ 8.00 Quantity:

(£11 on event day)

The Fun 5k Gym Bag

Price: £ 5.00 Quantity:

(£8 on event day)

Sunglasses

Price: £ 3.00 Quantity:

(£5 on event day)

Total

£ 0.00

Please tick to confirm this statement has been read*

Yes
Yes checked on behalf of a person under 18

I agree to take part in The Fun 5k (a 5k obstacle course run). I understand that in the absence of any negligence or other breach of duty by Yeovil Hospital Charity, Yeovil District Hospital and ACF Teambuilding & Events, their agents and their employees are insured against loss or injury through their negligence resulting from The Fun 5k. I understand that the chances of a serious injury are extremely low but minor injuries (bruises, bumps and grazes) are a possible result of taking part in an adventurous activity such as this. If participating in the event with a child, I understand that I am solely responsible for that child’s safety, before during and after the event. I will take every precaution to make sure the child I am accompanying is safe. I understand that all reasonable precautions have been taken to eliminate or reduce the risk of injury to myself whilst taking part. I am over 18 and I am not aware of any medical reasons why I should not take part in this event, and I agree to tell the organisers in advance of the run if one should come to light between now and the event. I understand that it will be my responsibility to decide if I am well enough to take part on the day.

Keeping you informed

We like to keep our supporters informed about the work of the charity. If you are happy to receive newsletters, updates and information about how you personally can help, please tick the boxes to let us know how you would like us to contact you.

Email*

Yes
No

Text*

Yes
No

Post*

Yes
No

Phone*

Yes
No

The Fun 5k

Multiple registrations

Please Note

Merchandise available to purchase for the event

Keeping you informed

Social community

Small print

Contact us

Tel: 01935 475122