Request edit access
Dare to Jump: Save Lives, 2019 - Registration Form
Complete your details to register for the 400ft Bungee Jump Challenge and ensure you return to the main page to pay your registration fee.

Please ensure you are aware of restrictions BEFORE you register:
- No under 14's
- Under 16s MUST have an adult with them
- Over 50’s are required to have a doctors certificate to comply with our insurance regulations
- Glasses and hard contact lenses cannot be worn
- Waist harnesses fit waist size of 40cm (15.7 inches) to 125cm (49.2 inches)
- Weight - Max 120kg

Full Name *
Your answer
Mobile Number *
Your answer
Email address *
Your answer
Age *
Your answer
Address *
Your answer
Post Code *
Your answer
City *
Your answer
How did you hear about this challenge? *
Does your employer have a match funding scheme? (Some employers will match/double the amount that you raise) *
What is your personal fundraising target? *
Any medical conditions we should know about? *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Number *
Your answer
I am happy for Penny Appeal to contact me with updates for future events and activities. (please tick box) *
Required
Any other comments?
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service