Anyone who would like to be considered for the Silver Bond place must pledge to raise a minimum of 1,000 plus (excluding Gift Aid)

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1 Silver Bond Application Form Diverse Abilities Virgin London Marathon 2016 Be amongst a diverse range of runners at the UK s biggest running event and run for Diverse Abilities! Diverse Abilities has been awarded one very special Silver Bond place for the Virgin London Marathon 2016 which the charity purchased from race organisers for 300 plus VAT. Anyone who would like to be considered for the Silver Bond place must pledge to raise a minimum of 1,000 plus (excluding Gift Aid) If you feel that you are able to raise this amount and would like to be considered for the place, please complete this application form and return by 15 th October 2015 to Sharon Wells, Events Fundraiser, Diverse Abilities, Unit C Acorn Business Park, Poole, Dorset. BH12 4NQ; or by to sharon.wells@diverseabilities.org.uk We will notify the chosen applicant by 17th October 2015 as to whether they have been successful in obtaining a place. Personal details: Please complete all details Title: Dr/Mr/Mrs/Ms/Miss First Name: Surname:.. Home Address:.....Postcode:....

2 Mobile Number: Home Phone Number: Date of Birth:.Gender: Male/ Female :. T-shirt: S / M / L/ XL Running Vest size: Chest size?. Employer:.. Job Title/Position:.. Work Address:..Postcode:.. Does your employer operate a matched giving scheme: Yes/ No If yes how much will they match Please tick the statement which applies to you: I have applied for a place through the official ballot Yes No This would be the first time I have participated in the London Marathon Yes No If this is your first London Marathon, please provide details of previous running experience: Have you fundraised for Diverse Abilities in the past? Yes No If yes, please provide details of the event and the amount raised: Have you raised funds for another charity before? Yes No If yes please name the charities, event and amount raised:

3 Please share your reasons as to why you would like to run for Diverse Abilities as a Silver Bond runner: Please continue on a separate sheet if necessary If you are allocated a Silver Bond place, please outline the ways in which you will raise at least 1,000 for Diverse Abilities. Please continue on a separate sheet if necessary Your declaration: I pledge to raise a minimum of 1000 for Diverse Abilities (excluding Gift Aid) in return for a Silver Bond place in the 2016 Virgin London Marathon. I also agree to the terms and conditions stated below. Signature of applicant: Date: Thank you for taking the time to complete this form. Please return by 15th October 2015 to Sharon Wells, Events Fundraiser, Diverse Abilities. Unit C Acorn Business Park, Ling Road, Poole, Dorset. BH12 4NZ or by to sharon.wells@diverseabilities.org.uk If you have any questions please call Terms and Conditions 1. I confirm that the information on this form is complete and correct 2. I confirm that I will be 18 years of age or older on the date of the event Contd

4 3. If allocated a Silver Bond place, I pledge to raise the minimum sponsorship amount (excluding Gift Aid), within two months of event completion 4. All applications are subject to a selection process to ensure that the marathon place is used to the best possible effect at the discretion of Diverse Abilities. 5. If allocated a Silver Bond place, I agree to inform Diverse Abilities as soon as possible if I am no longer able to take part in the event, at which point my minimum sponsorship obligation will cease 6. If I am unable to participate in the event for any reason all donated monies collected in support of Diverse Abilities will be forwarded to Diverse Abilities, or returned to the individual sponsors. Monies already received by Diverse Abilities will not be refunded 7. All participants enter at their own risk in accordance with the Virgin Marathon event s regulations 8. I also understand that by filling in this form, a member of the Diverse Abilities Communications team may contact me with regards to sharing my story Signed :. date:.

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