Step 1 of 3 33% Step 1 of 3Name* DrMissMrMrsMsMxProf.Rev.Other Prefix First Last Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Daytime phone numberMobile if different to the aboveEmail* Date of birth DD slash MM slash YYYY Step 2 of 3Occupation*Employer*Does your company run a matched-funding scheme?* Yes No Don't know - I'll ask Match funding is where your employer matches funds you raise, often £ for £ and sometimes up to a set amount for a charitable organisation, enhancing the amount you can raise for Shaftesbury! Step 3 of 3• It's fabulous you want to run with #TeamShaftesbury; do you have a personal link to Shaftesbury?If you have a good personal story to tell, would you be happy for us to share this with your local media? Always and only in collaboration with you: Yes No How did you hear about running this race for Shaftesbury?* Google Previous Shaftesbury runner Personal recommendation Shaftesbury website Shaftesbury enewsletter Facebook Twitter Terms and Conditions You confirm to the best of your knowledge, your general state of health and fitness is good, and you take full responsibility for your training. You take part at your own risk. Whilst there is no minimum sponsorship pledge or commitment to use your London Marathon own place to raise funds for Shaftesbury, by signing-up to Team Shaftesbury you agree to do your best to fundraise for the charity. You agree that Shaftesbury may use without payment, notice or further consent any photographs, videos and other images in which you appear that are taken at the event or event-related occasion in our marketing or promotional materials. Shaftesbury will not, however, identify anyone by name without their agreement. Special requirements* Do you have any special requirements that we need to know about i.e. allergies, medical conditions? Please give us the information we need to know about these*Declaration* I agree to these terms and conditions Privacy policy* I am happy to consent to the Shaftesbury Cookies and Privacy policy (click here to read this policy). We’d like to keep in touch and let you know how your support is transforming the lives of people with disabilities. We'll share more on our work, events and ways you can get involved. If you have supported us before we’ll continue to contact you in this way unless you tell us otherwise. Yes, please keep me updated by email Yes, please keep me updated by phone Yes, please keep me updated by text If you would rather not hear from us, or would like to change how we contact you, please do call our friendly supporter services team on 020 7452 2121 or email us at supporterservices@shaftesburygroup.org. Taking care of your information is important to us. Information about how we protect and use your personal data is set out in our privacy policy at dataprotection@shaftesburygroup.org
