Your Name:

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* 1. Your Name:

Your address:

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* 2. Your address:

Your contact number:

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* 3. Your contact number:

Your email address:

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* 4. Your email address:

Your occupation:

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* 5. Your occupation:

Your date of birth:

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* 6. Your date of birth:

Have you committed to doing any fundraising for a charity before? If yes please detail below.

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* 7. Have you committed to doing any fundraising for a charity before? If yes please detail below.

How much running are you currently doing?

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* 8. How much running are you currently doing?

Have you previously run a Marathon? If yes please detail below including times.

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* 9. Have you previously run a Marathon? If yes please detail below including times.

What is your connection to the Limbless Association? If none where did you hear about us?

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* 10. What is your connection to the Limbless Association? If none where did you hear about us?

Why do you want to run for the LA in the London Marathon?

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* 11. Why do you want to run for the LA in the London Marathon?

Our runners have been given a target of £2,500 for their fundraising. If a place was to come available by 1st January do you think that target is realistic for you? If not please advise how much fundraising you believe you could commit to.

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* 12. Our runners have been given a target of £2,500 for their fundraising. If a place was to come available by 1st January do you think that target is realistic for you? If not please advise how much fundraising you believe you could commit to.

If successful are you happy for us to promote your training and fundraising?

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* 13. If successful are you happy for us to promote your training and fundraising?

Would you like to be added to our email mailing list to be kept up to date with the charity, our services, fundraising news and opportunities?

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* 14. Would you like to be added to our email mailing list to be kept up to date with the charity, our services, fundraising news and opportunities?

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