The Great North Run 2016

Title*

First Name(s) in full*

Last Name*

Address Line 1*

Address Line 2

Town*

Postcode*

Date Of Birth

Daytime Telephone No:

Mobile Telephone No:

Email Address*:

I am happy to receive E-mails from Middlesbrough and Teesside Philanthropic Foundation*
YESNO

ALL APPLICANTS MUST BE AGED 17 OR OVER ON THE DAY OF THE RACE.
(Delete as appropriate) RELEVANT TO YOU AND READ CONDITIONS OF ENTRY.

Do you have an overseas mailing address?*
YESNO

Are you*
MALEFEMALE

Do you have a medical condition that the organisers should be made aware of?*
YESNO

Please indicate your running vest size*
Small (34”-36”)Medium (38”)Large (40”)X-Large (42”)XXL (44”-46”)

Are you a wheelchair entrant?*
YESNO

Preference into correct time zone will be given to runners who can validate proof of time by having completed in a previous Great North, or attach a highlighted race result in another half marathon.

How many Great North Runs have you completed?

Best time

Year completed

What is your estimated running time?

Would your participation story be of interest to local newspapers?
YESNO

If yes, please provide brief details of your story and we will contact you

OWN PLACE

I have secured my own place in the Great North Run 2016 and will run on behalf of MTPF*
YESNO

GUARANTEED PLACE

I wish to obtain a MTPF guaranteed place*
YESNO

I understand that by having a guaranteed place with MTPF that I need to pay a £50 entry fee at the time of submitting this application and that I will raise £250 in sponsorship.

You will be redirected to Paypal after you have submitted the form.

DISCLAIMER

I have read and I accept all the conditions of entry and acknowledge that the organisers shall not be liable for death, personal injury or loss or damage as a consequence of my participation in the Great North Run 2016 except with regard to personal injury which is caused by the organiser’s negligence.