Step 1 of 6 16% Butterfly Bimble Registration FormLead Ticket Holder DetailsThis field is hidden when viewing the formLead Ticket HolderPlease note: All postal and email correspondence about the event will be sent to the Lead Ticket Holder ONLY. The Lead Ticket Holder must be over 18.Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Name Surname Date of birth MM slash DD slash YYYY Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City County Postcode Do you have any medical conditions or allergies we should be aware of? Yes No Please summarise allergy/medical conditions(Required)Emergency Contact Details Please note: The information below will be used as the emergency contact details for everyone in your group unless specified otherwise.Emergency Contact Name First Name Surname Emergency Contact Phone(Required) Who else is attending?Would you like to add more tickets?(Required) Yes - I would like to register another person No - I am attending alone Why are you taking part?Who are you doing this in memory of/to celebrate?How did you hear about the Butterfly Bimble?Social MediaSearch Engine (e.g. Google)Friend or family recommendationEvent (e.g. another event held by Helen & Douglas House)Email or NewsletterOther(Please specify)Stay in touchWe may stay in touch with you by post, phone and social media with news from the hospice, information about events you might be interested in and other ways your fundraising can support terminally ill children. If you would also like to hear from us by email, please tick here.Email Opt In Yes, I'm happy to receive emails from Helen & Douglas House We take your privacy seriously. For more information about what we do with your data, please read our privacy policy at www.hdh.org.uk/supporter. You can opt-out of receiving this information, or having your data used in these ways, at any time by contacting us on [email protected] or 01865 799150. Terms & ConditionsI confirm that I wish to enter the Butterfly Bimble for Helen & Douglas House and understand that I do it at my own risk. Helen & Douglas House will not accept liability for any injury or loss that may occur as a result of my participation in the event. I agree that I am physically able to participate in the event. As lead booker I understand I must be over 18 and that I am responsible for any persons under 18 included on this booking and that all persons under 18 must be accompanied by an adult at all times whilst at the event. I understand that the use of Alcohol, smoking and drugs is not permitted at this event and HDH reserves the right to remove any participants found to be partaking in consumption of these substances. HDH reserves the right to cancel the event if deemed necessary. By entering the event you give permission for Helen & Douglas House to use any pictures or video footage taken of/by you on the day for promotional advertising or other uses as deemed appropriate - unless you specify otherwise. If a participant breaches any of the above terms and conditions HDH reserves right to terminate their place and remove them from the site. If a participant wishes to raise a complaint they can view our complaints policy here: Fundraising Complaints - Helen & Douglas HouseTick to confirm(Required) I have read and understand the Terms & Conditions Would you like to make a donation?The Butterfly Bimble is free to attend. If you would like to make an additional donation, we would be incredibly grateful. Your support helps us care for the children and families who need us, giving them precious time together and creating happy memories that last forever. £10 could fund ten suction tubes used in the medical care of terminally ill children. £20 could fund a play therapy hour session for a child, helping them learn and develop while having fun in a relaxed atmosphere. £50 could fund a two-hour bereavement counselling session, supporting families following the death of their child.Donation Amount Donation Total Gift Aid Add 25% more to your donation at no cost to you. A Gift Aid declaration allows Helen & Douglas House to claim tax back on eligible donations. It means that for every £1 you donate to Helen & Douglas House we can claim back 25p, at no extra cost to you. Tell me moreGift Aid Yes, I would like to claim Gift Aid By ticking the "Yes" box, I agree I would like Helen & Douglas House to reclaim the tax on all qualifying donations I have made, as well as any future donations, until I notify them otherwise. I understand that if I pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all my donations in that tax year I may be asked to pay any difference. I understand that Helen & Douglas House will reclaim 25p of tax on every £1 that I give. Booking Summary Payment DetailsCredit Card Total to pay
