Cycle Challenge Registration Form 2023 Welcome to the Pilgrims Cycle Challenge registration form, which can be used to register up to 4 people at a time. All participants must be at least 14 years old on 30th April 2023. A maximum of 1,000 participants are able to take part in the Pilgrims Hospices Cycle Challenge 2023, and last year's event sold out, so early registration is advised. Your details Title*Please selectMrMissMrsMsMxDrOtherOther* First name* Surname* Your Gender*Please selectMaleFemaleNon-binaryTransgenderPrefer not to sayYour date of birth* DD slash MM slash YYYY Address* Street Address Address Line 2 City County Postcode Contact details Contact mobile number*This should be the same number as the charged mobile phone you will have with you during the event.Email address* Enter Email Confirm Email Must be checked regularly (this is the most effective way for us to communicate event information with you)By submitting this form, you consent to be contacted by email for the purpose of this event. If you'd like to receive emails about other exciting ways to support Pilgrims Hospices or with news about our work, please tick the box below. I am happy to receive emails where possible You can update your contact preferences at any time by calling our Supporter Relations Team on 01227 782062 or by writing to us at Pilgrims Hospices, Supporter Relations, 56 London Road, Canterbury, Kent, CT2 8JA. We are registered under the Data Protection Act and will never share, sell or swap your details with any third party for the purposes on their own marketing or the monetising of your data. About your participation Are you part of a team? (If yes, please provide you team name or the name of the team captain) Choose your route* The Circuit - 30 miles The Classic - 50 miles The Challenge - 75 miles The Century - 100 miles The Epic - 125 miles Please note: All routes start and finish at University of Kent, Canterbury and you must complete your chosen route by 6.30pm at the latest. Emergency contact name* Emergency contact number*Are you taking part in memory of a loved one? If so, please provide their full name and relationship to you eg. John Smith (father)Do you have a sponsorship target you would like to achieve?Please select£100£250+£350+As much as I canWhere did you hear about this event?*Please selectPoster/flyer/bannerSocial mediaInternet searchWebsiteWord of mouthEmailPilgrims Matters magazinePostPilgrims volunteerFamily memberNewspaperOtherOther* Advanced Entry - Participant 1 Price: Would you like to register a second person? Yes Title*Please selectMrMissMrsMsMxDrOtherOther* First name* Surname* Gender*MaleFemaleNon-binaryTransgenderPrefer not to sayDate of birth* DD slash MM slash YYYY Under 18s must be accompanied by a participating adult and supervised at all times.Address (second participant)* Same as Participant 1 Street Address Address Line 2 City County Postcode Contact mobile number*This should be the same number as the charged mobile phone they will have with them during the event.Email address* Enter Email Confirm Email Must be checked regularly (this is the most effective way for us to communicate with you)Are they part of a team? (If yes, please provide your team name or the name of your team captain) Chosen route* The Circuit - 30 miles The Classic - 50 miles The Challenge - 75 miles The Century - 100 miles The Epic - 125 miles Please note: All routes start and finish at University of Kent, Canterbury.Emergency contact name* Emergency contact number*Are they taking part in memory of a loved one? (If yes, please provide their full name and relationship to you) eg. John Smith (father)Advanced Entry - Participant 2 Price: Would you like to register a third person? Yes Title*Please selectMrMissMrsMsMxDrOtherOther* First name* Surname* Gender*Please selectMaleFemaleNon-binaryTransgenderPrefer not to sayDate of birth* DD slash MM slash YYYY Under 18s must be accompanied by a participating adult and supervised at all times.Address (third participant)* Same as lead participant Street Address Address Line 2 City County Postcode Contact mobile number*This should be the same number as the charged mobile phone they will have with them during the event.Email address* Enter Email Confirm Email Must be checked regularly (this is the most effective way for us to communicate with you)Are they part of a team? (If yes, please provide your team name or the name of your team captain) Chosen route* The Circuit - 30 miles The Classic - 50 miles The Challenge - 75 miles The Century - 100 miles The Epic - 125 miles Please note: All routes start and finish at University of Kent, Canterbury.Emergency contact name* Emergency contact number*Are they taking part in memory of a loved one? (If yes, please provide their full name and relationship to you) eg. John Smith (father)Advanced Entry - Participant 3 Price: Would you like to register a fourth person? Yes Title*Please selectMrMissMrsMsMxDrOtherOther* First name* Surname* Gender*Please selectMaleFemaleNon-binaryTransgenderPrefer not to sayDate of birth* DD slash MM slash YYYY Under 18s must be accompanied by a participating adult and supervised at all times.Address (fourth participant)* Same as lead participant Street Address Address Line 2 City County Postcode Contact mobile number*This should be the same number as the charged mobile phone they will have with them during the event.Email address* Enter Email Confirm Email Must be checked regularly (this is the most effective way for us to communicate with you)Are they part of a team? (If yes, please provide your team name or the name of your team captain) Chosen route* The Circuit - 30 miles The Classic - 50 miles The Challenge - 75 miles The Century - 100 miles The Epic - 125 miles Please note: All routes start and finish at University of Kent, Canterbury.Emergency contact name* Emergency contact number*Are they taking part in memory of a loved one? (If yes, please provide their full name and relationship to you) eg. John Smith (father)Advanced Entry - Participant 4 Price: Show your support with the official Pilgrims Hospices Cycle Jersey and Neck Scarf The Pilgrims cycle jersey is a stylish, quality garment, packed with great features such as a zipped valuables pocket, full length zip and silicone waist gripper. The Pilgrims Hospice Neck Warmer is a multifunctional accessory suitable for all conditions and purposes. Benefitting from Hot & Cold technology, our Neck Warmers are designed to keep you warm when it’s cold, and to wick moisture away when it’s hot with our exclusive Qwick-Dri™ technology. What’s more, the lightweight nature of the fabric ensures it’s comfortable to wear for prolonged period of time.Sizes available: S, M, L, XL, XXL Jersey sizing guidePlease indicate the number of Pilgrims cycle jerseys you would like to add to your registration.None1 jersey (£35.00)2 jerseys (2 x £35.00)3 jerseys (3 x £35.00)4 jerseys (4 x £35.00)If you purchase one or more Pilgrims cycle jerseys, these will be dispatched to the address provided for the lead participant within the next 7 working days. (Once you enter a quantity above, you will be able to specify the size(s) required below)Size(s) of cycle jersey required* (XS, S, M, L, XL, XXL)Would you like to add any Pilgrims neck scarves to you registration? Yes Please indicate the number of Pilgrims neck scarves you would like to add to your registration. Quantity Price: £ 5.00 Quantity If you purchase one or more Pilgrims neck scarves, these will be dispatched to the address provided for the lead participant within the next 7 working days.I would like to add a donation to my entry of:Please select£10 could pay for a patient's meals for the day£20 could provide a physiotherapy session to help a patient stay active and enjoy time at home with their family£30 could enable our Community Team to hold a consultation with a patient in their own home.£45 could pay for one-on-one counselling for someone struggling to cope with the loss of a loved one.Other amountPlease enter your chosen donation amount:* Gift Aid - Increase the value of your gift by 25% Yes. Please treat all donations I make now, in the future, or have made to Pilgrims Hospices for the past 4 years as Gift Aid donations until further notice. I am a UK taxpayer and understand that if I pay less income Tax and/or Capital Gains Tax in the current tax year than the amount of Gift Aid claimed on all my donations it is my responsibility to pay any difference. I understand that Pilgrims Hospices will reclaim 25p of tax on every £1 that I have given. I am not a UK Taxpayer I understand that I take part in the Pilgrims Cycle Challenge at my own risk and that the organisers will not be liable for any injury or illness except where injury or illness is caused by their negligence and they are legally liable. I agree to abide by any terms and conditions of the event as agreed by the organisers. I undertake at all times to behave responsibly. I agree to follow any and all safety instructions given by the organisers before and during the event. By taking part in the event, I agree to Pilgrims Hospices, and their official photographers, using my name and any footage or photographs taken during my participation to be used in any future promotional material. (Please tick to indicate that you have read and agree to the disclaimer)* I agree Please ensure that you have completed the above form correctly before submitting. (Some autofill features can populate fields with incorrect data).Total £ 0.00