You're registering for Leicester Town and Gown 10k 1 Entry type2 Team details3 Your details4 Payment Entry TypeIndividualUKA AffiliatedJoin a TeamCreate a teamFind your team*Tip: Type the first letter of your team to find your team quicker. If your team is not listed, you will need to "Create a team".Select your team...Untitled_9Team name* Leicester Race Identifier*Are you paying for any other team members?NoYesHow many other team members are you paying for?1 Team member2 Team members3 Team members4 Team members5 Team members6 Team members7 Team members8 Team members9 Team members10 Team members First Team members detailsPlease fill out your first team members information, not your own details, you will fill out your own details on the next page. First team members name* First Last First team members email address* Enter Email Confirm Email First team members genderPlease select...MaleFemalePrefer not to sayFirst team members date of birth* First team members addressYour team members race pack will be delivered to the address you provide. If no address is given, they will need to collect the pack on the day of the race. Street Address Address Line 2 City County Post Code Second Team members detailsSecond team members name First Last Second team members email address* Enter Email Confirm Email Second team members genderPlease select...MaleFemalePrefer not to saySecond team members date of birth* Second team members addressYour team members race pack will be delivered to the address you provide. If no address is given, they will need to collect the pack on the day of the race. Street Address Address Line 2 City County / State / Region ZIP / Postal Code Third team members detailsThird team members name First Last Third team members email address* Enter Email Confirm Email Third team members date of birth* Third team members genderPlease select...MaleFemaleThird team members addressYour team members race pack will be delivered to the address you provide. If no address is given, they will need to collect the pack on the day of the race. Street Address Address Line 2 City County / State / Region ZIP / Postal Code Fourth team members detailsFourth team members name First Last Fourth team members email address* Enter Email Confirm Email Fourth team members date of birth* Fourth team members genderPlease select...MaleFemalePrefer not to sayFourth team members addressYour team members race pack will be delivered to the address you provide. If no address is given, they will need to collect the pack on the day of the race. Street Address Address Line 2 City County / State / Region ZIP / Postal Code Fifth team members detailsFifth team members name First Last Fifth team members email address* Enter Email Confirm Email Fifth team members date of birth* Fifth team members genderPlease select...MaleFemalePrefer not to sayFifth team members addressYour team members race pack will be delivered to the address you provide. If no address is given, they will need to collect the pack on the day of the race. Street Address Address Line 2 City County / State / Region ZIP / Postal Code Sixth team members detailsSixth team members name First Last Sixth team members email address* Enter Email Confirm Email Sixth team members date of birth* Sixth team members genderPlease select...MaleFemaleSixth team members addressYour team members race pack will be delivered to the address you provide. If no address is given, they will need to collect the pack on the day of the race. Street Address Address Line 2 City County / State / Region ZIP / Postal Code Seventh team members detailsSeventh team members name First Last Seventh team members email address* Enter Email Confirm Email Seventh team members date of birth* Seventh team members genderPlease select...MaleFemalePrefer not to saySeventh team members addressYour team members race pack will be delivered to the address you provide. If no address is given, they will need to collect the pack on the day of the race. Street Address Address Line 2 City County / State / Region ZIP / Postal Code Eighth team members detailsEighth team members name First Last Eighth team members email address* Enter Email Confirm Email Eighth team members date of birth* Eighth team members genderPlease select...MaleFemalePrefer not to sayEighth team members addressYour team members race pack will be delivered to the address you provide. If no address is given, they will need to collect the pack on the day of the race. Street Address Address Line 2 City County / State / Region ZIP / Postal Code Ninth team members detailsNinth team members name First Last Ninth team members email address* Enter Email Confirm Email Ninth team members date of birth* Ninth team members genderPlease select...MaleFemalePrefer not to sayNinth team members addressYour team members race pack will be delivered to the address you provide. If no address is given, they will need to collect the pack on the day of the race. Street Address Address Line 2 City County / State / Region ZIP / Postal Code Tenth team members detailsTenth team members name First Last Tenth team members email address* Enter Email Confirm Email Tenth team members date of birth* Tenth team members genderPlease select...MaleFemalePrefer not to sayTenth team members addressYour team members race pack will be delivered to the address you provide. If no address is given, they will need to collect the pack on the day of the race. Street Address Address Line 2 City County / State / Region ZIP / Postal Code Title*MrMrsMissMsDrYour Name* First Last Email*Your email address will be used to confirm your registration and keep you updated with essential information about the race you have signed up for only. Enter Email Confirm Email I'd like to be invited to future Town and Gown eventsBy not ticking a box we will not be able to let you know when future races open. Yes, by email Date of birth* Gender*Please select...MaleFemalePrefer not to sayAddress*Your race pack will be delivered to the address you provide. Street Address Address Line 2 City County Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Mobile*We will text your chip time to your mobile number when you cross the finish line.Emergency contact number*This number will only be used in the case of a serious injury on the event.Emergency contact name* First Last Running club nameUK Athletic NumberWill you be racing in a wheelchair?*Please Select...YesNoPredicted time*Please Select...Sub 40Sub 50Sub 6060+T-shirt size*Please Select...XSSMLXLHow did you hear about this event?Please Select...Banner outside parkEmail from Town and GownEvening StandardFacebookFlyerGoogleInstagramLeicester NewspaperMDUK EmailsMDUK WebsiteMetro NewspaperOnline AdvertPosterPrevious PatricipantRecommended by friend or familyTwitterPlace of workWhy have you chosen to support Muscular Dystrophy UK?Please Select...Just to runFamily Member has a muscle wasting condition (please specify)Friend/Work Colleague has condition (please specify)I have condition (please specify)OtherPlease specifyI'm happy to be contacted by Muscular Dystrophy UK to hear about latest news and other fundraising opportunities Yes, by email Yes, by post Yes, by phone Donation Amount£0.00£10.00£25.00£50.00£100.00£500.00Other AmountDonation amount Gift AidI confirm I have paid or will pay an amount of Income Tax and/or Capital Gains Tax for the current tax year (6 April to 5 April) that is at least equal to the amount of tax that all the charities and Community Amateur Sports Clubs (CASCs) that I donate to will reclaim on my gifts for the current tax year. I understand that other taxes such as VAT and Council Tax do not qualify. I understand the charity will reclaim 25p of tax on every £1 that I have given. You don’t necessarily have to be working to be paying tax. Apart from tax on income from a job or self-employment, the tax you’ve paid could include: tax-deducted at source from savings interest tax on State Pension and/or other pensions tax on investment or rental income (including tax credits on UK dividends) Capital Gains Tax on gains. Yes, I would like the Muscular Dystrophy UK to treat all gifts I have made in the past four years, today's gift, and all future gifts from the date of this declaration as Gift Aid donations. You are paying for 1 person. Price: £ 16.00 You are paying for 1 person. Price: £ 16.00 You are paying for 1 person. Price: £ 16.00 You're paying for 1 UKA Affiliated discount registration Price: £ 14.00 You are paying for 2 people Price: £ 32.00 You are paying for 3 people Price: £ 48.00 You are paying for 4 people Price: £ 64.00 You are paying for 5 people Price: £ 80.00 You are paying for 6 people Price: £ 96.00 You are paying for 7 people Price: £ 112.00 You are paying for 8 people Price: £ 128.00 You are paying for 9 people Price: £ 144.00 You are paying for 10 people Price: £ 160.00 You are paying for 11 people Price: £ 176.00 Terms & Conditions* I agree Race Terms & Conditions Read our Terms & Conditions Total £ 0.00 This iframe contains the logic required to handle Ajax powered Gravity Forms.
