Entry Number​
: Cottenham Yesteryear Road Run Entry Form ​
(for vehicles under 3 tons only) Vehicle Make: Model: Year: Driver’s Name: Reg No: Driver’s Signature: Owner's Home Address
Owner’s Name: Postcode Contact Number: Email: If you would like to be contacted by Arthur Rank Hospice Charity about our fundraising initiatives and news; please the relevant boxes.
I would like to recieve information by [ ] email [ ] post [ ] and/or telephone[ ]
DECLARATION I confirm that I wish to enter the Cottenham Yesteryear Road Run event. I understand that I do so at my own risk and that neitherthe
Cottenham Yesteryear Local Committee nor Arthur Rank Hospice Charity will be liable for any injury, damage or loss that may occur as a
result of my participation other than in respect of death or personal injury arising as a result of their negligence. I declare that during
the whole period of the event my entries will be covered by public liability insurance having a limit of indemnity, of not less than
£2,000,000. I further declare that my vehicle is roadworthy, registered and licensed and covered by insurance as required by the road
traffic act which is valid for the whole event as it takes place on public roads as defined in that act. I confirm that the driver of this vehicle
as entered holds a licence to drive a vehicle of the appropriate class and is covered by the vehicles insurance policy to drive the vehicle
entered. I consent that photographs taken during the Cottenham Yesteryear Road Run event may be used to publicise events and Arthur
Rank Hospice Charity in all media.
Name___________________________ Signature__________________________ Date:________________________ In order that we can make the most for Arthur Rank Hospice Charity, entry price is made up of two parts. £5 reflects the cost of the
ticket with a suggested donation of £5. This allows Arthur Rank Hospice Charity to ​benefit from Gift Aid on donations. Entry can be
requested without the suggested donation:
Total
I would like to pay the entry fee of £5
£______
Plus an additional donation of
£______
I would like to pay for lunch at £5 per person
£______
I am unable to attend but I would like to make a donation
of
£______
Closing date for entries: 27​th ​ ​March 2017
No entries will be accepted on the day
Please make cheques payable to:
Arthur Rank Hospice Charity
Return completed form and payment with a C5
stamped address envelope to:
Mrs Vivien Lampard,
319 High Street,
Cottenham, Cambridge
CB24 8TX
If you are a UK taxpayer, the value of your donations can increase by 25% under the Gift Aid scheme – at no
additional cost to you​ - Please tick the box below to join the Gift Aid scheme.
[ ] I have ticked the box as I am making a donation to accompany my entry fee and would like Arthur Rank
Hospice Charity (1133354) to reclaim the gift aid on this donation, any donations I have made in the past 4 years
and all future donations I may make, until I notify Arthur Rank Hospice Charity otherwise. I am a UK taxpayer and
understand that if I pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all my
donations in that tax year it is my responsibility to pay any difference.