Application ENTER NOW 2023 Ford RideLondon-Essex 100 Sunday 28th May 2023 Entry Fee Only £99 Fundraising - Only £350 Riders Details First name Last name Male Female Date of Birth Age Home Address Address line 1 Address line 2 Address line 3 City - town Postcode - zip Mobile Telephone - home Email Nationality Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic of The Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and The South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Predicted Time [hrs]:[mins]:[secs] T-shirt Please state size Small Medium Large X-Large Next of kin full name Next of kin telephone Next of kin email Work Details Work place name Occupation Work Address Address line 1 Address line 2 Address line 3 City - town Postcode - zip Telephone - work Email - work Fundraising I pledge to raise as much as I can for Get Kids Going! Please state amount below (minimum pledge £350). Thank you. I promise to set up a JustGiving page Yes No My company or workplace will match or contribute to the amount raised Yes No If yes please indicate amount My company or workplace contribution is on top of my fundraising pledge which I have stated above. Yes No Gift Aid Please tick the box below if you agree to Get Kids Going! collecting Gift Aid - ie: reclaiming the tax back from any personal donation given to the charity. I who have ticked the Gift Aid box above confirm I am a UK Income and/or Capital Gains taxpayer. I have read this statement and agree to Get Kids Going! reclaiming tax on any donation given to the charity from this date forwards until further notice. I understand that I must pay an amount of Income Tax and/or Capital Gains Tax, in the tax year, at least equal to the same amount of tax that all the charities and/or any community amateur sports clubs to which I donate, will reclaim on my gifts for that tax year. I understand that other taxes such as VAT and council tax do not qualify. I also understand Get Kids Going! will reclaim 25p of tax on every £1 that I donate. I will notify Get Kids Going!, in writing, if I no longer pay sufficient tax to qualify for Gift Aid. How did you hear of Get Kids Going! Important information Please note any kind donations given to Get Kids Going! cannot be returned. Entry fees are non refundable. Please contact us if we have not confirmed your entry within 7 working days.Email: [email protected] Tel: +44 (0)207 481 8110 I agree to the terms and conditions of entry laid down by the event organisers and Get Kids Going! Yes No Keep in touchHelp us turn dreams into reality for disabled children and young peopleWe would love to send you information on how we encourage disabled children and young people to participate in sport and how you can help us to turn their dreams of playing sport into reality through fundraising, events and volunteering opportunities. Please tick below to tell us how you would like to hear from us: Email Yes No Text Yes No Post Yes No Phone Yes No We take your privacy seriously and we will never sell or swap your details with third parties. You can tell us at any time to withdraw your consent by emailing us on [email protected]. Information on how we protect and use your personal data is set out in our privacy and cookies policy. Please note all of the above is a required field. Entry Fee PaymentYour secure entry fee payment will be taken by PayPal. Full name as stated on credit or debit card. Your entry fee of £99 will be taken at the next stage by PayPal. We accept all major credit and debit cards - except American Express or Diners.