Cycling Registration Form

Share this page
- Facebook
- Twitter
- Digg
- Delicious
- Google
Email it
Print it

denotes mandatory fields.

Which ride?

If other, please specify

Please select:

I have secured a place with the organisers - please send me a fundraising pack & vest I do not have my own place and would like to apply for a guaranteed entry I do not have a place of my own - please let me know when entry opens

Title:

If other, please specify

First name:

Last name:

Address line 1:

Address line 2:

Address line 3:

Town/City:

County:

Post code:

Email address:

I am happy to receive information about Breakthrough fundraising events by email or telephone

Yes No

Daytime telephone:

Evening telephone:

I confirm I am over 16 years of age:

Yes No

Date of Birth:

Company name:

Does your company operate a matched giving scheme

Yes No

Vest size:

How did you hear about cycling for Breakthrough in this event?

If other, please specify

Have you participated in a cycling event for a charity before?

Yes No

If so please provide details (which event, which charity, how much did your raise?)

How much sponsorship can you confidently pledge to raise?

Please provide details of any fundraising ideas you have to raise sponsorship for this event?

Please tell us why you want to bike for Breakthrough?

If you have been affected by breast cancer, would you be happy to talk to the media about your experience? (We will always contact you before approaching the media with your story)

Yes No

We may contact you in future to keep you informed about Breakthrough Breast Cancer's work and/or fundraising as well as the activities of our trading subsidiaries. If you would prefer not to receive these communications, please tick this box.

We may agree with carefully selected organisations to write to each other's contacts. If you wish to be excluded from these exchanges, please tick this box.

Print it
Share it
Back to top

In Focus

In focus

Highlights

In focus

Cycling Registration Form

Email it

Your message will be:

Email it

Your message will be: