Enter The Purbeck 16 – 2019 The Purbeck 16 (2019) The Purbeck 16 Entry Form - 2019 Step 1 of 6 16% 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 15-09-2019*Date of birth* DD MM YYYY Email* Expected Time*Sub 2 hrsSub 3 hrsSub 4 hrsSub 5 hrsPost Code* Street Address Address Line 2 City County / State / Region ZIP / Postal Code T Shirt not included in the entry fee.*Please ChooseI'd like to order a T shirt at £8 extraNo thanks.A T shirt is not included in the entry fee in 2019. If you would like to purchase one for £8 please select above.What size T-Shirt would you like?* Xtra Small Small Medium Large Xtra Large Are you a member of an affilliated club?*NoYesAffiliated 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 nearly 17 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 17 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 2017 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 FeePurbeck 16 T Shirt Fee*T ShirtPurbeck 16 T Shirt Fee - Not expecting to see this? you can go back and change your choice.ENTER DISCOUNT CODES HERE By using this form you agree with the storage and handling of your data by this website.* I Agree Admin fee £2 £ 2.00 This fee covers the costs and administration of online transactions.Total £ 0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 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 15th September 2019Thank 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 15th September 2019EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.