Your Full Name (required)

Your Address (required)

Your Postcode(required)

Your Email (required)

Age on Day of Event (required)

Your Main Contact Number(required)

T-Shirt Size (required)

Declaration

I wish to take part in the challenge and know of no existing medical condition that could prevent me from doing this safely. I am over the age of 18. I accept that the organisers of this event will not be responsible for any loss, injury, damage, death costs or expenses which may arise in consequence of participation in this event, however caused. I fully understand that Hospice of the Valleys has the right to refuse participation if it is deemed necessary. I also understand that in extreme weather conditions the event may have to be postponed.

The data we gather and hold is managed in accordance with the data protection act (1998). The Hospice of the Valleys will only use the information on this form for the specific purpose for which it was provided and will not pass it on or sell it to any third party. However we would like to occasionally send you information regarding other Hospice services or fundraising events and it is very helpful for us to understand why you have chosen to support us and how we can continue to keep you updated on our work and future events.

I would like to hear from Hospice of the Valleys in the futureI would not like to hear from Hospice of the Valleys in future

I would like to hear from you by EmailTelephoneMailSMS

I am interested in receiving The newsletterInformation on the monthly giving campaignInformation on fundraising events

To pay the entry fee:-
1 – Click the purple DONATE button in the top right of the screen
2 – Amend the amount to £50
3 – Type ‘3 Peaks entry fee’ in the free text/reference box
4 – Tick the box to ensure your name is displayed