Enter The Purbeck 16 – 2017 The Purbeck 16 The Purbeck 16 Entry Form - 2017 Step 1 of 5 20% Before you enter The Purbeck 16 we would like to offer you the opportunity to Run for charity and earn a free place? Simply pay for your place now, raise £250 for one of our charities and your entry fee will be deducted from the money you raise by your chosen charity. We'll send you an email with all the details once you have completed your entry form. Would you like to run for charity and get a free place?*Please SelectYes - sign me upNo thanks - it's not for mePlease ChooseWhich of our charity partners would you like to run for?*Please ChooseForest Holme HospiceAutism WessexLewis Manning HospiceJulia’s HouseBorder Collie RescueMargaret Green Animal RescuePlease Choose Your entry fee will be refunded to you by your chosen charity subject to you raising £250 for them. Your entry fee will not be refunded if you do not reach the £250 target. Please check the box below to confirm your agreement to these terms.* I agree Any additional comments or information you wish to pass on to your chosen charity?Thank you for choosing to run for charity! Please complete the entry form to get your place in The Purbeck 16.Thank you for choosing to participate in The Purbeck 16. Please complete the entry form to get your place. Name* First Last Gender*Please ChooseMaleFemaleAge on 17-09-2017*Date of birth* DD MM YYYY Email* Expected Time*Sub 2 hrsSub 3 hrsSub 4 hrsSub 5 hrsPost Code* ZIP / Postal Code What size T-Shirt would you like?* Small Medium Large Xtra Large Are you a member of an affilliated club?*Please ChooseYesNoAffiliated clubUKA Affiliation NumberTeam name (opt)Your Phone Number*Emergency Contact Name* First Last Emergency Contact Phone Number*Where did you hear about The Purbeck Marathon? Runners World Website Our Website Other website Running magazine Other press Other Race Instructions and Terms and Conditions*Please confirm that you have read our Race Instructions and our Terms and Conditions of entry? http://thepurbeckrunningfestival.co.uk/ Yes Please confirm that you are aware that The Purbeck 16 is actually 16.5 miles.* Yes Any additional comments or information you wish to pass on to the race organiserI DECLARE that on race day I will be fit to compete and over 18 years of age and will abide by the UK Athletics rules for competition. I accept that the organisers shall not be liable for any injury, illness or accidents as a consequence of my participation in this event. I will abide with the rules governing this event. I will carefully read all information sent to me prior to the event and I understand that this is a challenging, predominantly off-road event.* Please tick to confirm Please check if you are applying for your deferred place from 2016 This is a deferal request. Purbeck 16 Entry fee*Affiliated £25.00AffiliatedAffiliated Deferred*Deferred £10AffiliatedUnaffiliated Deferred*Deferred £10Unaffiliated DeferredPurbeck 16 Entry Fee*Unaffiliated £27.00Unaffiliated Entry FeeENTER DISCOUNT CODES HERE Hog & Beer*Would you like to join us for a hog roast and a beer after your run? Vegi pasta + sause option and wine available. Hog available 2-5pm. Bar & BBQ available from 12 noonPlease ChooseYes PleaseNo ThanksPlease choosePlease choseHog & Beer £9.00Vegi Option £9.00Admin fee £2 £ 2.00 This fee covers the costs and administration of online transactions.Total £ 0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Expiration Date Security Code Cardholder Name Once again thank you for choosing to run The Purbeck 16 for charity. You will shortly receive a confirmation email with further information. Good luck with your training and we'll see you on the 17th September 2017Thank you for choosing to run The Purbeck 16. You will shortly receive a confirmation email with further information. Good luck with your training and we'll see you on the 17th September 2017NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.