Your details

Title (required)

First name (required)

Surname (required)

Date of birth (required)

Address type (required)
HomeBusiness/Work

Address (required)

Town/City (required)

Postcode (required)

Telephone (required)

Email (required)

Please tell us why you are taking part (required)
I am a Pembridge patientPembridge are currently caring for my family member/friendI am cycling in memory of someone cared for by PembridgeI work at PembridgeI want to support my local hospiceThis will be a personal challengeSomeone roped me into it!

Your support helps our patients and families to live their lives to the fullest. We would like to keep in touch with updates on how you are helping and opportunities to take part in similar events in the future. Please let us know if you are happy to hear from us again.
I am happy to receive information by postI am happy for you to contact me by email

The Event

If your application is successful, we will give you a Pembridge cycle jersey to wear on the day. Please select your size below (required)
XSSMLXLXXL

Have you cycled this distance before?
100 miles75 miles50 miles25 milesNo

Expected finish time (required)

Fundraising

Why would you like to run for Pembridge Hospice Charity? Please tell us as much as you can. (required)

Your occupation

Your employer

Does your employer offer matched giving? (required)
YesNoI don't know

Would you be willing to share your story with the media? (required)
YesNoI don't know

As you know, there is a minimum sponsorship target of £500 for this event. How much do you expect to raise? (required)

Have you taken part in the RideLondon - Surrey 100 or fundraised through another event before? If so, please tell us what you raised and how you did it.

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