Miles for MindSpace Registration Form

Name

First NameLast Name

Email*

example@example.com

WalkJog/RunCycleOther

What has prompted you to take part in Miles for MindSpace & where did you hear about it?

YesNo

Please select your entry option by clicking on the box next to your entry. If you are buying more than 1 space, please adjust the quantity. If you would like to purchase a wrist band or T Shirt, please tick the box next the item and then adjust the quantity.

Adult Entry

£17.50 Quantity

Under 16 Entry

£12.50 Quantity

Family entry

£50.00 Quantity

Miles for MindSpace T-shirt

Tick the box and adjust the number of T Shirts you would like. Enter sizes in the box below

£20.00 Quantity
Item subtotal:£0.00

Miles for MindSpace Wrist band

Tick the box and adjust the number of wristbands you would like.

£2.50 Quantity

Total

£0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

If you have ordered a T Shirt, please enter the size you would like here:

T Shirts come in xs,s,m,l,xl,xxl

I do not want my Medal