RideLondon-Essex 100 Registration Form Welcome to the Ford RideLondon-Essex 100 application form Thank you for your interest in cycling in aid of Pilgrims Hospices. Things to know before filling out this form: Pilgrims Hospices has six guaranteed places in the Ford RideLondon-Essex 100 on Sunday 26 May 2024. These places are offered on a first-come, first-served basis to supporters for a registration fee of just £40 (including VAT) and a pledge to raise at least £395 sponsorship for local hospice care. All applicants must be at least 18 years old as of 26 May 2024. Your details Title*Please selectMrMissMrsMsMxDrOther Other* First name* Surname* Your date of birth* DD slash MM slash YYYY Your Gender*Please selectMaleFemaleNon-binaryTransgenderPrefer not to say Address* Street Address Address Line 2 City County Postcode Contact details Contact mobile number* Email address* Enter Email Confirm Email Must be checked regularly (this is the most effective way for us to communicate with you) By submitting this form, you consent to be contacted by email for the purpose of this event. If you'd like to receive emails about other exciting ways to support Pilgrims Hospices or with news about our work, please tick the box below. I am happy to receive emails where possible You can update your contact preferences at any time by calling our Supporter Relations Team on 01227 782062 or by writing to us at Pilgrims Hospices, Supporter Relations, 56 London Road, Canterbury, Kent, CT2 8JA. We are registered under the Data Protection Act and will never share, sell or swap your details with any third party for the purposes on their own marketing or the monetising of your data. About your participationEmergency contact name* Emergency contact number* Where did you hear about our charity places in the RideLondon-Essex 100?*Please select...WebsiteSocial MediaEmailPilgrims volunteerPrevious participantPilgrims MattersWord of mouthOther Other* Do you have a sponsorship target you would like to achieve?£395+£500£750+£1,000+ Please list some examples of how you intend to raise this sponsorship: Please give details about the reason you wish to cycle in the RideLondon-Essex 100 in aid of Pilgrims Hospices: Are you taking part in memory of a loved one? If so, please provide their full name and relationship to youeg. John Smith (father) Would you be happy for us to use your fundraising story in hospice publicity (e.g. to promote our RideLondon-Essex 100 places)? Yes No Does your employer have a match giving scheme that you can apply to in order to boost your fundraising? Yes No Not sure Name of company/employer I confirm that I wish to participate in the Ford RideLondon-Essex 100 on Sunday 26 May 2024 for Pilgrims Hospices. I confirm that all the information provided by me in this form is to the best of my knowledge true and correct. I understand that if any information provided by me in this form is found to be false, I risk withdrawal from the Ford RideLondon-Essex 100 and the loss of my registration. By taking a Pilgrims Hospices charity place, I pledge to raise at least £395 for Pilgrims Hospices. (Please tick to indicate that you have read and agree to the disclaimer)* I agree Entry fee - Ford RideLondon-Essex 100 Pilgrims charity place* Price: