Big Wheel 2025

My Details

First Name *

Last Name *

Email *

Phone Number *

Date Of Birth *

If under 18 I can confirm I am cycling with someone over the age of 18

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Gender *

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My Address

Address Line One *

Address Line Two

Town/City *

County

Postcode *

Country *

Emergency Contact

Please provide a name and telephone for your emergency contact who will not be taking part in the event with you.

Emergency Contact name

Emergency Contact Number

Medical Conditions

Does the participant have a pre existing medical condition?

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How did you hear about the event?

Do you have a connection to St Michael's Hospice?

Let's keep in touch

Your support helps us care for people living with a life-limiting illness in North Hampshire and we look forward to keeping in touch with you by post and phone, sharing our news, activities and appeals. Please tick if you would like to receive our emails:

Yes, I would like to receive emails

Donations

If you are unable to ask for sponsorship, please consider a donation if you can. £10 will fund a child bereavement activity book to help a child struggling with the loss of their relative. £35 will enable a patient or family member to access 1 hour of specialist support from our Hospice at Home team. £110 could provide pain relieving medication to a patient for 8 days, enhancing their wellbeing and keeping them comfortable.

Choose an amount:

�10

�35

�110

Other (�)

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Gift Aid Declaration:

* I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax in the current tax year than the amount of Gift Aid claimed on all my donations it is my responsibility to pay any difference.

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My Details

Create or Join a Team

My Address

Emergency Contact

Medical Conditions

Tell us more

Let's keep in touch

Donations

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