Team Name

Contact Name

Telephone No.

E-Mail Address

Team Members

Are buggies required? Please indicate how many.

Please advise of any special requirements, including, dietary requirements.

How many team(s) would you like to enter for the above event @ a cost of £495

Payment to be made to The Richard Goldberg Foundation

Bank Details - Sort Code: 40.27.15 / Account No: 74831276

Reference as Team Name. Once your payment has been received your team will be confirmed.