Enter The Purbeck 5K 2019 The Purbeck 3 (5K) The Purbeck 3 (5K) Entry Form - 2019 Step 1 of 6 16% Before you enter The Purbeck 5K we would like to offer you the opportunity to Run for charity and earn a free place? Simply pay for your place now, raise £75 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?*Yes - sign me upNo thanks - it's not for mePlease ChooseWhich of our charity partners would you like to run for?*Forest Holme HospiceAutism WessexLewis Manning HospiceJulia’s HouseBorder Collie RescueMargaret Green Animal RescuePlease ChooseYour entry fee will be refunded to you by your chosen charity subject to you raising £75 for them. Your entry fee will not be refunded if you do not reach the £75 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 5K.Thank you for choosing to participate in The Purbeck 5K. Please complete the entry form to get your place. UntitledFirst ChoiceSecond ChoiceThird ChoiceName* First Last Age on 15-09-2019*Date of birth* DD MM YYYY Email* Address* 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. If you would like to purchase one you can do so here.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 Running Festival? 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 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 11 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 Purbeck 3 (5K) Entry fee*Affiliated £10.00AffiliatedPurbeck 3 (5K) Entry Fee*Unaffiliated £12.00Unaffiliated Entry FeePurbeck 3 (5K) T Shirt Fee*T Shirt @ £8Not expecting to see this? You can use the 'Previous' button to 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 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 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 16th September 2018Thank 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 16th September 2018EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.