Tough Mudder UK 2015 Gold Bond application form To apply for a place, please complete and sign this form and return with your entry fee of £75 to: Events Team, The National Autistic Society, 393 City Road, London, EC1V 1NG Personal details Name _________________________________________________ Date of birth _________________________ Address ___________________________________________________________________________________ ______________________ Postcode ______________ Email ________________________________________ Daytime phone ________________________________ Mobile _______________________________________ Employer ____________________________________ Job Title _______________________________________ As we are a charity we would like to keep our costs down and ensure that your event materials reach you as quickly as possible. If you would prefer to receive information via email please tick here  Fundraising Pledge You must pledge to raise a minimum of £500. How much do you hope to raise? ___________ How do you plan to do this?_______________________________________________________________________________________ The Challenge If you are taking part with a friend or team please give us their name or your team name __________________________ Please Tell us which event you wish to take part in (i.e London west & date)_________________________________ Please tell us what size t-shirt you would like  S  M  L  XL Name you would like on your running vest (8 max iron on letters) ___________ Please tell us… Where you heard about this event _________________________________________________________________ If you have a link to autism ______________________________________________________________________ Are you happy to be involved in any publicity or have your photo used?  Yes  No Entry Fee In order to secure a place in your chosen Tough Mudder event you must pay an entry fee of £75. This includes a t-shirt, refreshments and mechanical support.  I enclose a cheque made payable to The National Autistic Society for £75  I wish to pay for my entry fee with my debit or credit card (or call 0808 800 1050 to pay over the phone). Please debit £75 from my _____________________________________ (card type) debit / credit card Name on card ______________________________________________________________________ Card number _______________________________________________________________________ Valid from ____/____ Expiry date ____/____ Security code (last three digits) _____________ Billing Address (if different to the address above)___________________________________________ __________________________________________________________________________________ Please turn over… NASW

Terms & conditions of entry …continued Keeping in touch It really helps The National Autistic Society if we can keep you informed about our work and how you can help us. If you would prefer us not to contact you for this purpose, please tick this box.  If we are keeping in touch with you, doing so by email will help keep our costs down. Please tick this box if you are happy to receive such information from us by email.  Terms & conditions of entry By registering Tough Mudder 2015 (and paying your £75 non-refundable entry fee) you are pledging to raise at least £500 for The National Autistic Society (NAS) which you undertake to send to the NAS no later than four weeks after the event. You agree to represent and raise money exclusively for the NAS in this race. Of sponsorship monies raised, approximately £100 will be used to cover the costs associated with your participation in this challenge. The remainder of your minimum sponsorship amount, £150 and any additional funds raised will go directly towards the work of the NAS, and cannot be restricted to any particular programme, service or branch of the NAS. You must ensure that your sponsors are aware that part of your minimum sponsorship will cover your challenge costs. Some participants choose to pay their challenge costs themselves, so they can tell their sponsors that all their money is going to the NAS and ensuring that, in appropriate cases, we can recover gift aid. Should you have to withdraw for any reason, you should inform the NAS in writing, send all sponsorship forms and money collected directly to the NAS, and notify your sponsors that you are no longer taking part. All sponsorship monies will be retained by the NAS unless your sponsors request in writing that the NAS return it to them within one month of your cancellation (not applicable for online donations). If you withdraw from the challenge after date, you will be asked to pay an administration fee of £50 so that NAS does not lose money invested in the event and used to support your place. The organiser, Tough Mudder, specialises in challenges of this nature and is solely responsible for organising and running the event, including the safety of participants. Neither the NAS nor Tough Mudder will accept liability for any injury, loss or damage unless it arises from the negligence of the NAS or Tough Mudder as the case may be. The swapping or sale of race numbers is strictly prohibited for reasons of safety and primarily for identification by medical staff You should take out personal injury insurance covering you to take part in this event. You must complete the race on foot and not introduce any wheeled vehicle. You must not suffer from alcohol or drug dependency, nor have any criminal convictions that are not disclosed at the time of applying to participate. You will be responsible for providing your own personal equipment. You must be at least 18 years old before the departure date of the event. We advise that you train for the event and prepare for your challenge. If you have not exercised for some time, you should consult your doctor for a check up and abide by any advice given. Your commitment I apply to take part in Tough Mudder UK 2015 and confirm that I have read and agree to the above terms and conditions of entry. Signature Name (capital letters) Date ____________________________________________________________________________ The National Autistic Society is the UK's leading charity for people affected by autism. With your support we can make a positive difference to even more people living with autism. The National Autistic Society is a company limited by guarantee registered in England (no. 1205298) and a charity registered in England and Wales (269425) and in Scotland (SC039427), registered office 393 City Road, London, EC1V 1NG.