1. Prudential RideLondon- Surrey 100 Sunday 31 July 2016 Registration Form To register for a place in the 2016 Prudential RideLondon-Surrey 100, please complete and return this form by Friday 15 April 2016 to: Elly Badcock, Events Team, The National Autistic Society, 393 City Road, London, EC1V 1NG Personal details Title _______ Forename _________________________ Surname ___________________________________________ Address _________________________________________________________________________________________ ___________________________________________________________________ Postcode _____________________ Daytime phone _________________ Mobile __________________ Email _____________________________________ Employer _________________________________ Job Title ________________________________________________ Fundraising Pledge You must pledge to raise a minimum of £500 for RideLondon-Surrey 100. How much do you hope to raise? ____________ How do you plan to do this?____________________________________________________________________________ __________________________________________________________________________________________________ Please tell us… Where you heard about this event _______________________________________________________________________ If you have a link to autism _____________________________________________________________________________ Are you part of a team? ________________________________________________________________________________ Are you happy to be involved in any publicity or have your photo used?  Yes  No Please tell us what size t-shirt you would like:  S  M  L  XL Registration Fee In order to reserve your place on the RideLondon-Surrey 100 cycling challenge you must pay a registration fee of £50.  I enclose a cheque made payable to the National Autistic Society for £50  I wish to pay for my registration fee with my debit or credit card. Please fill in details below or call 0808 800 1050 to pay over the phone. Please debit £50 from my _____________________________________ (card type) debit/credit card Name on card _____________________________________________________________________________________ Card number ______________________________________________________________________________________ Valid from ____/____ Expiry date ____/____ Security code (last three digits) ____________ Issue No:______ Billing Address (if different to the address above) _________________________________________________________ _________________________________________________________________________________________________ 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 

2. 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. Terms & conditions of entry 1.By filling out this registration form for the Prudential RideLondon-Surrey 100 cycling event and paying your £50 non-refundable registration fee you are pledging to raise as much sponsorship money as possible for The National Autistic Society (NAS), and a minimum of £500 per person, to be received by NAS no later than 4 weeks after the event. 2.You agree to represent and raise money exclusively for the NAS in this challenge. 3.Of sponsorship monies raised, approx. £240 will be used to cover the costs associated with your participation in this challenge. The remainder of your pledged minimum sponsorship amount 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. 4.You must ensure that your sponsors are aware that part of your pledged 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. 5.The NAS or the organisers, the London & Surrey Cycling Partnership may, at their sole discretion, withdraw a participant before or during the challenge. This right is only likely to be exercised for health and safety reasons. 6.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). 7.You will be responsible for providing your own personal cycling equipment and wear a cycle helmet at all times when cycling. 8.You must be at least 18 years old on the date of the event. 9.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. 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.  Your Commitment I confirm that to the best of my knowledge my general health and fitness is good and I take the responsibility for my fitness to take part. I am registering to take part in RideLondon-Surrey 100 and confirm that I have read and agree to the 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. Over 700,000 people in the UK have autism. Together with their families they make up over 2.8 million people whose lives are touched by autism every single day. Despite this, autism is still relatively unknown and misunderstood. Which means that many of these two million people get nothing like the level of help, support and understanding they need. Together, we are going to change this.