Registration

• Title*
• First name*
• Surname*
• Email*
• Please confirm your email address*
• Telephone (day)*
• Mobile
• Date of birth* Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
• House number*
• Address*
• Address2
• Address3
• Town/city*
• County
• Postcode*

• Event name or description *
• Venue
• Event date Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2012 2013 2014 2015 2016 2017
• Please select from the drop down list the type of event that best describes your fundraising activity * Overseas Cycling event UK based Cycling event Running event Celebration e.g. birthday or wedding Church event Community event e.g. cake sale, a ball, football match School event Swimming event Overseas trek or walk UK based trek or walk Triathlon Walking event An event at work Other
• Is anyone else fundraising with you through the event? Yes No
• If yes, how many people?
• Are you Fundraising with a group? Yes No
• If yes, who are you fundraising with?
• Please enter their name(s) and email address(es) if they'd like to be contacted by us
• How much do you aim to raise through this event? £
• Please include further details about your planned fundraising activity below, and any specific support you'd like to receive from us
• Are there any other charities benefiting from your event? If yes, which charities?
• Do you have any other requests at this stage?

• Please select if you would like a top to wear and we'll send this to you in time for the event Running vest T-shirt No top
• Size S M L XL XXL
• We'll send you iron on letters so that you can add your name to the front of your event top. If you'd like this lettering, please enter a name to add to your top (this is for running events so people can cheer you on).

• Have you taken part in an event for Mind before? If yes, please let us know which event this was in the space provided. Yes No Previous event details
• Do you have experience of mental health issues? I've personally had experience A direct family member has had experience My friend My partner I work in the mental health field Other – please specify
• Please use this space to provide us with any further information about your reasons for supporting Mind
• Are taking part in this event in memory of a loved one? Yes No
• If you are, what relation is this person to you? Partner Spouse Son or daughter Sibling Parent Close relative Friend Colleague Other
• Do you have a story that will inspire others? Mind is always looking for newsworthy articles. If so, would you be happy for our press team to contact you? Yes No

• Where did you hear about the charity?* Poster Events organizers website Newspaper Other Radio Postcard Friend Work Mind shop Mind website Magazine advert TV Google search
• Please include further details below
• I understand that I am undertaking this fundraising event at my own risk and Mind shall not be liable in any way for any damage, harm or loss that might occur from my event. I also agree to follow the guidelines set out in Mind's fundraising Guide in relation to branding, lotteries, raffles, insurance and fundraising law. I will endeavour to obtain and pay to Mind all monies raised within 4 weeks of my fundraising event and understand that any funds raised through this event will support the work of National Mind.
• 
  We would also like to keep you up to date with Mind's work, and details of other activities (including fundraising). Please tick this box if you would like to receive this information via email.
• Please tick this box if you would prefer to be contacted by post or telephone.

I understand that any information provided by me in connection with Mind may be recorded and used by Mind in accordance with the Data Protection Act 1998