DIVERSE ABILITIES PLUS CHALLENGE
REGISTRATION FORM
We will accept photocopies of this form.
In BLOCK CAPITALS, please fully complete ONE form PER person taking part, if entering as a group
please staple the completed forms together and send with the registration fee to:
Fundraising, Diverse Abilities Plus, Unit C, Acorn Business Park, Ling Road, Poole, Dorset. BH12 4NZ
Tick below the route you would like to run :10k
8k
2.3k fun run
T Shirt Size:
Small
Medium
Large
Extra Large
JINGLE JOG
Moors Valley Country Park
Sunday 7th December 2014
Walk, jog, hop or skip your way around Moors Valley, embracing the festive season
Choose from 10k, 8k and 2.3k routes
Title: .......... First Name: ............................................. Last Name: ...........................................................
Address: .....................................................................................................................................................
..................................................................................... Post code: ...........................................................
Day Time Tel: ............................................................. Mobile Tel: ............................................................
Email:.................................................................................... Date of Birth:......................... (if under 18)
I will be supervised by (full name):..........................................................................................................
(please also supply a parental/guardian consent letter to you taking part in this event when sending
in your entry form & payment, if under 18, thank you)
How did you hear about this event:........................................................................................................
Paying by Cheque:
I enclose a cheque for £ ............................ for my registration fee, made payable to:
“Diverse Abilities Plus”
Do you have a special reason for taking part, and if so, what is it? ............................................................
..............................................................................................................................................................................
Are you happy for Diverse Abilities Plus to use your story and/or photo to promote and publicise
fundraising events and the charity?
Yes
No
Signed: ............................................................................. Date: ..............................................................
(Cheque only for postal entries please. The charity is unable to refund entry fees. In the event of
participant cancellation or non-attendance, the entry fee will be treated as a charitable donation)
Declaration
I understand that if I am in any doubt about my health or have a medical condition that could
be affected by taking part in this event, I should obtain my GP’s approval before entering and
participating. I acknowledge that I take part in this event at my own risk and that Diverse Abilities
Plus or it’s sponsors cannot be held liable for any loss, damage or injury caused or sustained as a
result of my participation safely in this event.
I understand this is a sponsored fundraising challenge event and I pledge to raise the minimum
required and I understand that the entry fee/s are non returnable as they cover the costs of
administering this event.
I understand that Diverse Abilities Plus may take photographs of me taking part in this event and
permit them to use the images for promotional purposes; if signing for a child. I give permission to use
their image.
I understand that Diverse Abilities Plus may contact me regarding other charity activities but will not
share my details with any third party.
Enter online:
www.diverseabilitiesplus.org.uk/events
E-mail:
[email protected]
Telephone
01202 718266
Charity no. 282197
Diverse Abilities Plus is Dorset’s disability charity,
founded in 1955 by a courageous local mum whose
daughter was born with cerebral palsy. We are proud to
have grown to now support 500 children and adults with
physical and learning disabilities here in Dorset.
Charity no. 282197
Diverse Abilities Plus – Dorset’s disability charity
Jingle Jog
Diverse Abilities Plus is the only charity that has been supporting children and adults
with profound physical and/or learning disabilities, and their families, through a range
of services in Dorset for 59 years. The charity provides a range of assistance, support
and education services for young people aged two to 19, adults with disabilities, and
their families. We focus on the positives and aim to give those we support a fantastic
life and an encouraging future through a range of services.
If you fancy spreading some extra Christmas cheer this year then this is the event
for you. Join us in this beautiful woodland location to walk, jog, hop, skip or run
your way around a choice of routes to suit you. Funds raised from the Jingle
Jog will ensure the charity’s vital services continue over the festive season and
beyond. By taking part in this event you will be helping to provide the people we
support with a Christmas they will always treasure.
By providing round the clock care and support, we give a little bit of sunshine to
the people we support, making sure they have everything they need to have an
enjoyable and fulfilling life. Our services are full of fun, laughter and joy and service
staff work extremely hard to support the people’s needs and ensure every day is fun,
rewarding and challenging.
Please complete one entry form per person and staple multiple forms together if
coming in a group. Please also attach a parental/guardian consent note for all
children (aged 18 or under)
Diverse Abilities could not run its services without the support of the local community.
By getting involved and taking on your own challenge will make a huge difference
to the people we support.
With your support £15 is enough to provide a music therapy session for a child at our
specialist school.
£50 could purchase some fantastic sensory toys and equipment for use across
Diverse Abilities Plus’ services.
£130 could send a child with disabilities on an amazing adventurous activity that
they’ve never experienced before, such as camping.
£300 is enough to train a volunteer advisor, to support many people and families
facing difficulties due to disability.
Entry Fee/Sponsorship
Children 5yrs and under FREE (2.3K route only and must be accompanied by a
paid parent/or guardian participant)
6 to 17 years old: £5 Entry Fee (£15 min sponsorship)
Adults 18+: £10 Entry Fee (£30 min sponsorship)
Minimum Age:
There is no minimum age to take part in this event. All are welcome, children
must be accompanied by a parent/guardian throughout the day. Children
under the age of 16 must be joined by a paid parent/guardian participant
throughout the route you choose to partake in.
Register your interest online: