Add Your Creative (Advert, Banner, text etc)

Title
—Please choose an option—MrMissMrsPrefer not to disclose

First Name

Surname (Last name)

Your email

Phone Number

Date Of Birth

Address - House Name/Number

Your Town

Postcode

Any Medical condition we should know about?

Emergency contact name (Not attending the event)

Emergency contact number

What is your T-Shirt size?
XSmallSmallMediumLargeXLXXL
I am happy for Charity Socials to contact me with updates for future events and activities of this nature.
YesNo
How did you hear about UKIM?
Choose one pleaseTVRadioWord of MouthSocial Media
Are you physically fit for this challenge?
YesNo
I understand that my booking will only be confirmed after I have paid the initial, non-refundable admin fee. Additionally, I am required to raise funds on JustGiving to meet the target set by the charity I am connected with. I will await further instructions from the Charity Socials Team after submitting this form and completing my payment on the next page.