Sign-up for the 150km walk challenge

Sign up now for your free fundraising pack and t-shirt and help us to continue providing life changing support for people living with epilepsy.

Who will you be taking part with?*

Individually/with friends/with family

With work colleagues

At school or college

Name of company

Name of school/organisation

Which month will you do your challenge?*

What is your overall fundraising target?

Get yourself kitted out in an Epilepsy Action T-shirt

Which size would you prefer?

Small

Medium

Large

Extra large

Your details

Title

Name*

First Last

Email*

Phone*

Complete your address below:*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Why are you taking part in the 150km challenge?*

I have epilepsy

I care for a child with epilepsy

I care for an adult with epilepsy

A family member or friend has epilepsy

My work involves people with epilepsy

In memory of someone with epilepsy

Other (please specify)

Terms and conditions

All funds raised will be in aid of Epilepsy Action and I agree to send donations within six weeks of the event. I understand that I am liable for any costs or risks that arise from organising a fundraising event. I agree that I cannot deduct costs of the event from donations, unless approval has been gained from Epilepsy Action in advance. I agree to ask permission before taking and sharing any photographs of people at my event.

I agree

Are you over 16?*

I am 16 or over

I am under 16

If you are under 16 we require your parent or guardian’s consent for you to take part in an event in aid of Epilepsy Action. If you are under 16 please have your parent or guardian complete this form.

Keep in touch

We’d love to keep in touch with you about our latest news and campaigns, and how you can support our life-changing work. Please select yes below so you can hear from us:

Yes

Phone

Yes

Text

Yes

Epilepsy Action will never swap, share or sell your details. For more information, read our privacy policy. You can update your preferences at any time by contacting our supporter care team on 0113 210 8800 or emailing supportercare@epilepsy.org.uk

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