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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 *
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Email address *
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Age *
Your answer
Address *
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Post Code *
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City *
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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 *
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Emergency Contact Number *
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I am happy for Penny Appeal to contact me with updates for future events and activities. (please tick box) *
Any other comments?
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