Enter The Purbeck Ultra 2019 The Purbeck Ultra (2019) The Purbeck Ultra Entry Form Step 1 of 5 20% Before you enter The Purbeck Ultra we would like to offer you the opportunity to Run for charity and earn a free place? Simply pay for your place now, raise £350 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 £350 for them. Your entry fee will not be refunded if you do not reach the £350 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 Marathon.Thank you for choosing to participate in The Purbeck Ultra. Please complete the entry form to get your place. Name* First Last Gender*Please ChooseMaleFemaleAge on 14-09-2019*Date of birth* DD MM YYYY Email* Expected Time*Please ChooseSub 6 hrsSub 7 hrsSub 8 hrsSub 9 hrsSub 10 hrsSub 11 hrsAddress* Street Address Address Line 2 City County / State / Region ZIP / Postal Code What size T-Shirt would you like?* Small Medium Large Xtra Large Thank you for your donation. We appreciate it and will ensure it's used wisely. Are you a member of an affilliated club?*NoYesAffiliated clubUKA Affiliation NumberTeam name (opt)Let us know the name of the team that you are part of . Make sure the spelling is entered the same by all team members.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 Ultra is nearly 54 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 2018 This is a deferal request. ENTER DISCOUNT CODES HERE Purbeck Ultra Entry fee*Affiliated £48.00AffiliatedPurbeck Ultra Entry Fee*Unaffiliated £50.00Unaffiliated 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 By using this form you agree with the storage and handling of your data by this website.* I Agree Once again thank you for choosing to run The Purbeck Marathon 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 Ultra. You will shortly receive a confirmation email with further information. Good luck with your training and we'll see you on the 14th September 2019.NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.