Tell us about your event Your DetailsName* MrMrsMissMsDrProf.Rev. Prefix First Last Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* PhoneEvent DetailsPlease use this space to tell us about your fundraising plans.Event Name* What type of activity or event are you planning?*For example, a social event like a coffee morning or bake sale, a personal challenge such as a run, bike ride or a skydive, or other fundraising event, like a head shave or sponsored silence. Are you doing this as part of a team or individually?Date of your Event / Activity* MM slash DD slash YYYY What is your personal fundraising target? (£) Promoting your fundraisingLet us know how we can share details of what you're doing.Are you happy for us to share details of your fundraising activity and your reasons for fundraising on our website and social media to help celebrate your efforts and achievements?** Yes No I'm not sure, please contact me regards this If you have set up an online fundraising page and you would like us to share, please enter it here:You can find out how to set up a page to support us at https://www.justgiving.com/hahcarlise Do you have a special reason for choosing Hospice at Home to benefit from your Fundraising? If in memory: Name of Individual you are remembering We appreciate every fundraising pledge made to Hospice at Home, and understand that this pledge will have meant a lot to you and the person you are remembering. In order to recognise this, we ask to record the name of the person you’re remembering and any reason you may have for organising this event. We ask this so we can provide a more personalised thank you letter to you, and to recognise the tribute you’ve made to them and their support of Hospice at Home. However, if you would rather keep this anonymous this is of course fine and we respect your decision.If you have set up a Facebook page / website you'd like us to share, please enter it here: Do you have a poster or photos of you related to your fundraising that you would like to upload?By sending these, you give consent to Hospice at Home to use the photo(s) you have uploaded to help promote your fundraising on our website, within our shops and social media. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB. Fundraising ResourcesWe have a number of free resources that you can use to help promote your fundraising and Hospice at Home - depending on stock availability.Please select what you would like, if anything: I do not require any resources 2 x Collection Tins 2 x Collection Buckets Donation Gift Aid Envelopes - for individual donations (x20) Recent Contact magazine (x5) Ballons (10) Hospice at Home T-Shirt*I do not require a T-shirtHospice at Home Yellow T-shirt - Size SHospice at Home Yellow T-shirt - Size MHospice at Home Yellow T-shirt - Size LHospice at Home Yellow T-shirt - Size XLIf requesting resources, where would you like to collect them from?*Our team will be in touch to let you know when your resources are ready to collect. Please note due to delivery times, collection from shops may take up to 10 days.Hospice at Home Office, DalstonHospice at Home Shop - BramptonHospice at Home Shop - CarlisleHospice at Home Shop - PenrithHospice at Home Shop - WigtonKeep in touchTo process the information about your event / activity we will need to add your details to our secure database. Please visit www.hospiceathome.co.uk/privacy/ for further info. You can withdraw your consent from marketing information any time by calling 01228 475025 or by emailing admin@hospiceathome.co.ukWe’d love to keep in touch with you about the work of Hospice at Home Carlisle and North Lakeland and how your money makes a difference to local patients, their families and carers, as well as updating you on future events, volunteering opportunities and other general news Yes please, I would like to hear updates and news from you by email Yes please, I would like to about volunteering opportunities from you by email Email communication To help the charity remain as cost effective as possible we would like to send you thank you correspondence via email. If you are happy to receive such emails please tick this box