Summer Sign Up

Please read the application form first, then complete the following details in full as it is a legal document required for insurance purposes. Membership details will be held on computer and signing this form indicates your agreement to this. All details will be for internal use only and will be treated in confidence and not shared with 3rd parties. Illegible forms will be returned for completion.

 1. Choose your Challenge

  • Walking
  • Running
  • Cycling
  • A combination of walking, running and cycling

2. Choose your Distance

  • Walking – 6, 10, 15, or 26.2 miles
  • Running – 6, 10, 15, or 26.2 miles
  • Cycling – 30, 60 or 125 miles

3. Pay securely Online

Saturday 16th June 2012
Sunday 17th June 2012
I will be requiring accommodation at The Academy on 16th (Bring your own tent) - £5
I will be requiring a hot meal at The Academy on 27th - £6
I will be requiring overnight parking - £2
Are you under 16?

Total Cost: £0

Full payment for the challenge must be made at the time of registration. No refunds will be given for any reason so please only register if you are sure you can attend the challenge. The Challenge will continue regardless of weather conditions. No application form will be accepted without full payment. Cheques should be made out to ‘The Academy’. Applications should be sent to The Academy, Church Farm, Church Road, Barrow, Bury St Edmunds, Suffolk. IP29 5AX. England

First Name
Surname
Country
Date of Birth (Format DD/MM/YYYY)
Sex
Nationality
Full Postal Address
Postcode
Email which we may use to contact you
Member of any athletics club? Yes No
If yes, which athletics club?
Home Telephone No.
Mobile Telephone No.
Emergency Contact Name
Relationship
Emergency Contact Number
Where did you hear about us?
Which charity/good cause are you raising money for? (If applicable)
Are you in good health? Yes
No
Please detail any known illnesses below. For example MIGRAINE / EPILEPSY / HAYFEVER / RESPIRATORY PROBLEMS (i.e Asthma) HEART DISORDERS / HAEMOPHILIA / NERVOUS DISORDERS / DIABETES.
Are you doing the challenge for Alzheimers Society
I would like to make a donation to (name your charity) for
£. This will be forwarded to your chosen charity.

I wish to take part in The Great Barrow Challenge and confirm that I am in good health and believe that I may be able to complete the challenge physically, and I agree to comply with all conditions laid down by the organisers, and to abide by any instructions given by the organisers. I accept full responsibility for my health while I am engaged on the Great Barrow Challenge and I understand and acknowledge that I am taking part in a strenuous activity which carries the risk of injury, serious injury or death and I know no reason why I should not participate on the challenge. I agree to walk/run or cycle at my own risk, and I indemnify the organisers of any claim for accident or injury or any claim arising for any reason as a result of the challenge howsoever caused. I also accept responsibility all my personal belongings, vehicles and equipment which may be lost or damaged by whatever means while at the Great Barrow Challenge, both at The Academy Health & Fitness Centre in Barrow and also along any of the routes.
I confirm that I have taken out a suitable insurance policy for the Challenge and understand that this may have to be produced if requested prior to the event.

By registering the participant also agrees to the possible use by the Organisers of his/her personal details and/or image in print, on photograph, film or video etc, for promotional or informative purposes in the interest of the Great Barrow Challenge, without being entitled to demand payment.

The event is photographed by an official photographer whom you herby authorize to take photographs of yourself and also allow the photographs taken at the event to be displayed on the photographers website. These photographs will be available for purchase from the website and will also be made available to the organisers of the event to use for promotional or informative purposes.

I have read and accept the above conditions