Event registration

Welcome to the Swim Serpentine application form. Thank you for your interest in taking the plunge for Pilgrims Hospices.

Things to know before filling out this form:

- We have a limited number of charity places in the 1-mile & 2-mile events at Swim Serpentine. These are offered on a first-come, first-served basis via this online form only.

- We ask 1 mile swimmers to pledge to raise £200 for Pilgrims Hospices (excluding Gift Aid) and 2 mile swimmers to pledge to raise £250 for Pilgrims Hospices (excluding Gift Aid).

- All applicants must be at least 16 years old as of 16 September 2023.

- Please note: Pilgrims places in the 2-mile swim have now been filled. You can still apply to swim the 1-mile challenge.

Your details

Title*

Other*

First name*

Surname*

Your Gender*

Your date of birth*

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 participation

Choose your distance

1-mile swim

Please note: Pilgrims Hospices charity places in the 2-mile swim have now been filled.

Emergency contact name*

Emergency contact number*

Please give details about the reason you would like to take on the Swim Serpentine for Pilgrims Hospices.*

Are you taking part in memory of a loved one? (If yes, please provide their full name and relationship to you)

eg. John Smith (father)

Where did you hear about our charity places in Swim Serpentine?*

Other*

Would you be happy for us to use your fundraising story in hospice publicity (e.g. to promote our Swim Serpentine places)?

Yes
No

Does your company 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 Swim Serpentine 2023 in aid of 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 Swim Serpentine. By taking a Pilgrims Hospices charity place, I pledge to raise at least £200 (1 mile swim) / £250 (2 mile swim) for Pilgrims Hospices. (Please tick to indicate that you have read and agree to the disclaimer)*

I agree