Tough Mudder

Tough Mudder

Distance

5k Event Locations and Dates

10k Event Locations and Dates

15k Event Locations and Dates

First Name(s) in full:

Surname / Family Name

Date of birth

Address 1

Address 2

City

County

Post Code

Mobile Number

Emergency Contact Name

Emergency contact telephone

Please state your reason for wanting to take part

Are you running in memory of someone?

Is the person you are running in memory of a blood relative?

Please give their full name:

What is your relationship to them?

Has a memorial fund been set up for this person?

Employer:

Occupation:

Does your employer operate a matched giving scheme?

How did you find out about the event?

If I am accepted for a CRY place I will be honour-bound to raise a minimum of £250 (including a £50 non refundable deposit). Gift aid cannot be included in your total fundraising amount. Please note the Tough Mudder is a core fundraising event for CRY and all money raised will go towards our core funding initiatives. It is, therefore, not possible to allocate sponsorship raised using CRY places, to ring-fenced memorial funds.

How do you hope to achieve this?

Do you know how much they are willing to match?

Would you like a CRY Unisex T-shirt?

Size T-Shirt

How did you hear about CRY?

Have you taken part in an event for CRY before?

Please provide the name of the event

Year of the event

We like to keep all our supporters and fundraisers informed of all CRY developments. May we have your permission to add you to our...

CRY Monthly Enewsletter & Raising Awareness Campaign emails

CRY Update magazine - 3 times / year via post

CRY Fundraising places and events emails

CRY Medical Conference & research news

In response to an increasing number of approaches to CRY by people who have, or are related to people with heart conditions and who also want to take part in physical challenges (running events, parachute jumps, overseas adventures treks, etc.) in aid of CRY, the Charity now has a policy relating to health checks, for the protection of individuals undertaking such activities.

If you select a category that requires further action, it is in your interest to supply the required information as soon as possible, as there is a significant demand for these places. CRY will hold the place open for you for one month but cannot guarantee to extend the offer beyond this date. CRY will not be able to confirm your place until documentation is received by CRY in the form of a letter or email from you that shows your cardiologist has agreed to your participation. Please note that individual doctors from CRY’s Centre for Inherited Cardiovascular Conditions at St George’s Hospital, Tooting, are not able to assist you unless that doctor is your cardiologist.

Please check the four statements below carefully, selecting to indicate which one applies to you, and then press the Submit button below:

Statement 1: I have a cardiac condition and have been assessed by a consultant cardiologist or I am currently being monitored for a cardiac condition.

Statement 2: I have a family history of cardiac conditions that can cause and/or has caused young sudden cardiac death and have been assessed by a consultant cardiologist. Please note: family history includes any first-degree blood relative (parent, son, daughter or sibling) who has a cardiac condition or has died suddenly of a cardiac condition.

Statement 3: I have a family history of cardiac conditions that can cause and/or has caused young sudden cardiac death and have not been referred to a consultant cardiologist for assessment. Please note: family history includes any first-degree blood relative (parent, son, daughter or sibling) who has a cardiac condition or has died suddenly of a cardiac condition.

Statement 4: None of the above categories applies to me. I confirm that, to my knowledge, I do not have a cardiac condition and I do not have any first-degree blood relatives who have a cardiac condition that can cause and/or has caused young sudden cardiac death. Therefore, I am entering the event at my own risk.

As statement 1 applies to you, we require a letter or email from you stating that you have discussed with your consultant cardiologist your wish to participate in the (insert event name) and after an informed discussion assessing the benefits and potential risks, you and your cardiologist have agreed that you can participate in the (insert event name). Please copy and paste the following text into a letter or email and send this confirmation to CRY at the address given below.

Dear CRY

I have discussed my cardiac condition with my cardiologist with regard to my wish to participate in the (insert event name). After an informed discussion assessing the benefits and potential risks, my cardiologist has agreed that I can participate in the event. I have read, understood and agree to CRY’s terms and conditions and I accept all the risks inherent in this event.

Yours, etc

As statement 2 applies to you, we require a letter or email from you stating that you have had cardiac tests carried out by a consultant cardiologist and the consultant cardiologist has confirmed you do not have a cardiac condition which could cause sudden cardiac death or would in any way limit your ability to participate in the (insert event name). If you have been diagnosed with a cardiac condition then please refer to statement 1. Please copy and paste the following text into a letter or email and send this confirmation to CRY at the address given below.

Dear CRY

I have had cardiac tests carried out by a consultant cardiologist and the cardiologist has confirmed that I do not have a cardiac condition which would cause sudden cardiac death or would limit my ability to participate in the (insert event name). The cardiologist has agreed that I can participate in the event. I have read, understood and agree to CRY’s terms and conditions and I accept all the risks inherent in this event.

Yours, etc

As statement 3 applies to you, we will forward details of how to be referred to a specialist. We appreciate that time may be a factor in obtaining the relevant clearance to participate in an event. However, conditions which cause young sudden cardiac death are often genetic and there are clear clinical guidelines within the NHS which stress that after a young sudden death or a diagnosis of a family member with a genetic condition all first-degree blood relatives should be referred to a cardiologist with a specialist interest in inherited cardiac conditions. If you wish to be referred to CRY’s Centre for Inherited Cardiac Conditions at St George’s Hospital, Tooting, then contact CRY at events@c-r-y.org.uk to obtain referral details.

MEDICAL RESTRICTIONS

You should be fit to take part in this event and you are strongly advised to undertake the appropriate training. If you have any doubts about your ability to take part including, without limitation, having pre-existing medical conditions you should contact your doctor to seek advice. CRY recommends that anyone with a cardiac condition should not participate in this event.

IMPORTANT NOTICE

I voluntarily accept all the risks inherent in this event and I agree for myself and my personal representatives to indemnify and hold harmless Cardiac Risk in the Young (CRY) against any claim or claims whether on my own account or from third parties arising out of any accident or incident resulting in any loss or damage (including bodily injury and death).

Preventing young sudden cardiac deaths through awareness, screening and research, and supporting affected families.

01737 363222

cry@c-r-y.org.uk

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