Julie B Full AC form

URL

This field is for validation purposes and should be left unchanged.

Please select a preferred date(Required)

Friday 18 September

Saturday 19 September

If you have no preference please select both dates

How many people will be taking part in the challenge?

Name - if there is more than one participant please provide details of lead booker(Required)

First Last

Address(Required)

Street Address City County Postcode

Email(Required)

Enter Email Confirm Email

Phone(Required)

Please provide details of any dietary requirements

Emergency contact 1

Emergency contact 2

Please let us know what t-shirt size you require

Name2(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

Emergency contact 1

Emergency contact 2

Please provide details of any dietary requirements

Please let us know what t-shirt size they require

Are you happy for this t-shirt to be sent to the lead booker address?

Yes

Please provide details of where the t-shirt should be sent.

Street Address Address Line 2 Town/City County Postcode

Name3(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

Emergency contact 1

Emergency contact 2

Please provide details of any dietary requirements

Please let us know what t-shirt size they require

Are you happy for this t-shirt to be sent to the lead booker address?

Yes

Please provide details of where the t-shirt should be sent.

Street Address Address Line 2 Town/City County Postcode

Name4(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

Emergency contact 1

Emergency contact 2

Please provide details of any dietary requirements

Please let us know what t-shirt size they require

Are you happy for this t-shirt to be sent to the lead booker address?

Yes

Please provide details of where the t-shirt should be sent.

Street Address Address Line 2 Town/City County Postcode

Name5(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

Emergency contact 1

Emergency contact 2

Please provide details of any dietary requirements

Please let us know what t-shirt size they require

Are you happy for this t-shirt to be sent to the lead booker address?

Yes

Please provide details of where the t-shirt should be sent.

Street Address Address Line 2 Town/City County Postcode

Name6(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

Emergency contact 1

Emergency contact 2

Please provide details of any dietary requirements

Please let us know what t-shirt size they require

Are you happy for this t-shirt to be sent to the lead booker address?

Yes

Please provide details of where the t-shirt should be sent.

Street Address Address Line 2 Town/City County Postcode

Name7(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

Emergency contact 1

Emergency contact 2

Please provide details of any dietary requirements

Please let us know what t-shirt size they require

Are you happy for this t-shirt to be sent to the lead booker address?

Yes

Please provide details of where the t-shirt should be sent.

Street Address Address Line 2 Town/City County Postcode

Name8(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

Emergency contact 1

Emergency contact 2

Please provide details of any dietary requirements

Please let us know what t-shirt size they require

Are you happy for all t-shirts to be sent to the lead booker address?

Yes

Please provide details of where the t-shirt should be sent.

Street Address Address Line 2 Town/City County Postcode

Do you or anyone in your party have a spinal cord injury or any other mobility issues?(Required)

Yes

Please could you tell us more about your wheelchair use?(Required)

I am a full time manual wheelchair user

I am a full time electric wheelchair user

I am a full time wheelchair user and I could use either a manual or electric

I can walk a few steps (with or without a walking aid)

Not a wheelchair user

Self-transfer (lift and shift)

I use a slide board/banana board/transfer board

I usually use a hoist

Other

Please could you provide more information

It would be helpful for us to know, what your usual transfer method is?(Required)

Self-transfer (lift and shift)

I use a slide board/banana board/transfer board

I usually use a hoist

Other

Please provide more details

If you usually use a hoist: Please note: There is no hoist available at the abseil or canoeing site.

How can we best assist you on the day?(Required)

Canoes will be provided with standard seating. If you require additional support we have some equipment available. Please indicate your preference:(Required)

Yes, I would need additional stability support such as a brace, extra padding, etc.

I will be fine using the standard canoe seat

What is your preferred method of travelling to each activity?(Required)

Travel on the minibus

Make your own way and follow the minibus in your own vehicle

If you wish to travel in the minibus, are you able to transfer from your wheelchair to a minibus seat?(Required)

Yes

N/A

Other

Please provide more information

Fundraising declaration and acknowledgement of registration fee(Required)

I agree to pay a £70 registration fee with a suggested fundraising target of £300

Please enter the number of people registering for the challenge on this form. (Required)

Price: £ 70.00

Total

Your contact preferences

We would like to keep you informed about our campaigning and services, appeals and others ways you can support our work. Your support and involvement with SIA helps us to empower people with spinal cord injuries and their families to live fulfilled lives.

How would you like us to contact you?(Required)

Phone

Post

I do not wish to be contacted by SIA

Why we will contact you
By joining SIA, you’ll receive information about our charitable activities and the support services we provide. Please let us know what other information you’d like to receive using the options below.
SIA Communications – regular updates concerning our work, including our campaigning, the events we organise and how you can support us now and in the future.
Training and Education – providing you with information about SIA’s training and education providing vital specialist expertise across the health and care sector.
The Voice – SIA's monthly email newsletter providing updates on all our activities.

Please tick below to let us know the type of communications you would like to receive from us:

SIA communications

Training and education

The Voice

Your contact preferences

Why we will contact you