Bungee Jump sign-up form

Title

First name Required

Surname Required

Job title (if applicable)

Date of birth

Email address Required

Contact number Required

Address

Address 1

Address 2

City

State/Province

Country

Postal Code

How did you hear about us?

Select event from drop-down Required

Tick here if you would support a particular hospital, department or care organisation

If so, please provide details in the 'tell us about your fundraiser' section.

Tick here if you have previously fundraised for NorthCare Charity

If yes, please provide details in the 'tell us about your fundraiser' section.

Tell us about your fundraiser

Would you like a free charity t-shirt? Please select a size

Declaration Required

I confirm all funds are voluntarily given and accepted without expecting or receiving something in return. I will comply with fundraising laws and recognised fundraising standards when organising any fundraising activities.

Contact details Required

I confirm NorthCare Charity can contact me about my participation in this event via the details I have provided in this form. I hereby declare that all personal information is voluntarily given and is accurate to the best of my knowledge.

I agree to receive NorthCare Charity’s newsletter to my email address so I can find out how my support helps patients and staff across the Northern Care Alliance. I understand I can unsubscribe at any time by emailing northcarecharity@nca.nhs.uk.

I agree to the privacy policy.

Bungee Jump sign-up form

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