Ride London 2019 Note: Please do not fill out this form unless you have been sent the link via email. Ride London Fundraiser Agreement 2019 LHM Guaranteed Charity Place Entry Fundraiser AgreementTo be eligible for a charity place for the Ride London 2019, please complete the form below. You will then be directed to the payment page.Name* 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 IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Have you taken part in any cycling events in the past?*How much do you hope to raise? (Please note, there is a minimum sponsorship of £600 for this event.)*Any questions or comments?AgreementsRegistration Fee*• I agree to pay a non-refundable registration fee of £50 (plus transaction fee of £2.50) • I understand that my place is not guaranteed until this fee has cleared • I will inform Little Hearts Matter immediately if I am unable to take part in the event. All monies paid to Little Hearts Matter to this point may be non-refundable and treated as a donation. Agree Donations & Payment Terms*• I pledge to raise a minimum of £600.00 for Little Hearts Matter through my participation in the Event • I understand that all sponsorship monies must be paid to Little Hearts Matter within 30 days of the Event taking place • I will use a sponsorship form to collect details of my offline sponsors and any possible Gift Aid declarations and send these to Little Hearts Matter following the Event. • I will, if the sum of £600 has not been paid in by one month after the event, pay the remainder from my own personal funds within one month of this date or in instalments to be agreed with Little Hearts Matter in writing • I understand that Gift Aid cannot count towards the £600 minimum sponsorship total Agree Fundraising*• I will only collect money for Little Hearts Matter in connection with the Event • I will only use lawful means to fundraise for Little Hearts Matter and will not do anything that is likely to harm Little Hearts Matter’s reputation • My fundraising will not include door to door collections, street collections (without first obtaining written permission from the local authority), collections on private property (without first obtaining written permission from the property owner), or conducting a raffle or lottery at a public event • I agree that Little Hearts Matter can terminate my authority to fundraise on their behalf at any time by sending written notice to the address given by me. Agree Personal data*• I give permission for the free use of my name, picture, image, feedback and comments in any future publicity, advertising or fundraising materials, including on the internet and social media sites • I give permission for my personal data to be stored and used by Little Hearts Matter in connection with the organisation, promotion and administration of the event (you can opt out of being contacted below) Agree Health and safety*• I take part in the event at my own risk and will not hold Little Hearts Matter responsible for any accident, injury or illness sustained to the fullest example possible in law • I will fully prepare myself for the physical challenge of the event and I will check with my doctor to ensure that I am medically fit to participate in the event • I will comply with any health and safety guidelines and any other rules issued by the event organisers Agree PaymentRegistration fee payment* Price: £ 52.50 Total £ 0.00 Declaration and signatureBy signing (initialing) this form, I confirm that I will be 18 years old on Sunday 4th August 2019 and I accept all of the points stated in the fundraiser agreements. I will pay my non-refundable registration fee of £52.50 and understand that my place cannot be confirmed until payment has been received and cleared.Signed (Initials):*Name:*Date:*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 I would like to receive occasional updates from LHM via email I would like to receive occasional updates from LHM via post