Full Name:Date of Birth: Address: Postcode: Why are you taking part? Employer: Occupation: How did you hear about this? Home No: ______________________________ Mobile No: _____________________________ __________________________________ Name of your dance Partner: _________________ _________________________ Have you had any formal training: Yes /No ‘Yes’ won’t exclude you, but will help us to decide on the format of the lessons etc. Application Form Please fill out one application per person Please read and sign the terms and conditions overleaf In aid of St Luke’s (Cheshire) Hospice

Terms & Conditions - please read very carefully before committing yourself I, (please print name)______________________________________________ confirm that: Starting 20 September 2015, I commit to attending regular tuition for 2 hours per lesson over an 8 week period at The Lifestyle Centre, Winsford, Cheshire CW7 1AD. Start time 2pm. I’m free all day on Saturday 21 November 2015 for rehearsals, hair and make-up and the Finale Show at The Lyceum, Crewe. I agree to pay a £25 registration fee (refundable if I raise more than £400) and a £50 deposit. This deposit is purely to cover our costs should you need to pull out of the event at any point, but is fully refundable if you complete the dance lessons and compete at the finale on 21 November. I will aim to raise a minimum of £350 per person (£700 per couple) for St Luke’s (Cheshire) Hospice. I will endeavour to sell a minimum of 10 tickets to family and friends to come and watch the performance at The Lyceum on Saturday 21 November (all tickets must be bought in advance). I understand that places are limited and filling out this application form does NOT guarantee my place. Due to the nature of the event and for general health and safety reasons, I understand that I will need to invest in a pair of professional dance shoes. I am physically fit enough to take part in St Luke’s (Cheshire) Hospice Strictly Learn to Dance 2015 competition. I will comply with all instructions given to me by the dance teachers and event organisers, and I understand that I am participating at my own risk. I understand that the Judge’s decision is final. ____________________________________________________________________________ Signed: ……………………..………………………………………. Dated: ………….……………………………… Please return your form and payment to Catherine Moore, St Luke’s (Cheshire) Hospice, Grosvenor House, Queensway, Winsford CW7 IBH. Data Protection Act. St Luke’s (Cheshire) Hospice will process your personal data for the purpose of your entry to and participation in ‘Strictly Learn To Dance’. We may also keep you informed about our work, promotions and future events. If you would prefer not to be informed about future events please let us know by writing to the Fundraising Team, St Luke’s (Cheshire) Hospice, Grosvenor House, Queensway, Winsford, Cheshire CW7 1BH. Photography consent. By taking part in this event, you are consenting to have your picture taken in both stills and video format by the Hospice and outside sources. These images may be used indefinitely to promote the work of St Luke’s Cheshire Hospice for fundraising activities.