Please remember that the fields below which are marked with a  *  are required fields. Please read and complete our Important Request below if you wish to be contacted in the future for other events.

Title: First Name: *
Last Name: *
Company Name:
Address Line 1: *
Address Line 2:
Town/City: *
County/State: *
Postcode: *
Country: * Tel Number(mobile): *
Tel Number(home):
E-mail Address: *

The Cardholder is the person paying the entry fee by credit or debit card. Tick if it is the same as above, otherwise clear the fields and type in the cardholder data.

Cardholder Name:
Cardholder Address Line 1: *
Cardholder Address Line 2:
Cardholder Town/City: *
Cardholder County/State: *
Cardholder Postcode: *
Cardholder Country: * Cardholder Telephone Number: *
Cardholder E-mail Address: *

Number of Tickets:
Lunch Cost:
Name of table host/organiser (if known):

For table bookings and larger groups please email or call.

I wish to sponsor a pony in the Shetland pony race for £300. There will be 12 runners in the race.

I would like my racing colours to appear in the racecard for £100.

Colours description:
Name registered with Weatherbys:

I am unable to attend but would like to make a donation:

I would like The Bob Champion Cancer Trust to benefit by reclaiming from the Government tax of 25p on every £1 of my donation. and all future donations.

If you would like to print a copy of this form, please do so before clicking the submit button.

Or send your payment with this application form to: Lucy Wilkinson, Bob Champion Cancer Trust, 7 Square Rigger Row, Plantation Wharf, London SW11 3TZ.

For more information please call 020 7924 3553 or 07973 133685 or email lucy@bobchampion.org.uk

Registered Charity Number: 1024664