‘On Your Marks for Little Hearts’

Application Form

Before you complete the form, please read through the following information.

These entry fees will cover the charity’s costs in organising and running the event. It also means that any sponsor money which you raise will go directly towards supporting the work of Little Hearts Matter.
Please can cheques be made payable to ‘Little Hearts Matter’
Fields marked with a * are mandatory


Race Attending: (e.g. Shugborough, Worthing)

Personal Details
* Title:
* First Name:
* Last Name:
Age
* Date of Birth:
If under 18 years of age (please complete)
Parent / Guardian Name Address (if different from below)
Parent Name
*Parent Address 1:
Parent Address 2:
Parent Address 3:
Full Postcode:
Company Details
Company Name
Contact Details
* Address 1:
Address 2:
Address 3:
* Full Postcode:
* Email:
* Telephone (Home):
* Telephone (Work):
* Telephone (Mobile):
Distance Entered
10K (Over 16's) 5K (11 and over) Fun Run (10 & Under)
Please tick the boxes relevant to you
Do you have a medical condition that the Organisation should be made aware of?
If yes, please give details
Please tick here to confirm that you have read and understand and accept the terms and conditions of the race rules Race Rules
Personal Information Thank you for your support, Little Hearts Matter (LHM) will use your personal information for administration purposes and to provide you with services or information that you have requested. We greatly value your support and would like to keep you informed through marketing literature by post and email about our work or our events.
Please tick the box if you would prefer not to hear from us

If you do not wish to fill in the form please print and return along with payment to: - Little Hearts Matter, 11 Greenfield Crescent, Edgbaston, Birmingham, B15 3AU Telephone: 0121 455 8982, Email: info@lhm.org.uk Website: www.lhm.org.uk