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* 1. Pub Name

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* 2. What is your full name?

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* 3. Address

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* 4. Date of Birth

Date

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* 5. Weight in kg

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* 6. Height?

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* 7. Which activity/ activities are you interested in?

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* 8. What is the name of the charity you would like to raise money for?

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* 9. Which charity scheme would you like to use?

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* 10. Comments, questions or concerns

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