Supporting

       The Bedford Hospitals

     Charity Duckling Appeal.

             ONLINE  ENTRY  FORM

Bedford School Pool - Saturday 21st November 2009

Team Name..................................................................................................................................

Team Captain................................................................................................................................

Address.........................................................................................................................................

.....................................................................................................................................................

.

Postcode.........................................................

Telephone .............................................................Email................................................................

I confirm, as Team Captain, that I am over 17 years of age.. (Please check box)

Sponsorship

Either :

 We nominate The Bedford Hospitals Charity Duckling Appeal to receive all sponsorship - (please tick here)

or:       

Our Team's Registered Charity (to receive 50% of sponsorship collected)

            Name:  ......................................................................................

            Charity number:   ......................................................................

                     (if no Registered Charity is nominated then all of Sponsorship will go to the Bedford Hospitals Duckling Appeal )

Preferred Swimming Start Time: (Hourly from 9.00 a.m. to 3.00 p.m.)

(1) ................................................ (2)..........................................................(3).................................................

TEAM MEMBER'S NAMES

               (Teams to consist of UP TO 6 swimmers. Names may be submitted later if not known at time of Team Entry.)

Team Member 1 ..............................................................................         

Team Member 2 ..............................................................................  

Team Member 3 ................................................................. .............         

Team Member 4 ...............................................................................  

Team Member 5 ..............................................................................         

Team Member 6 ...............................................................................  

                                                                                        Last Entries - 14th November 2009

Please also send in a cheque for £10 (ten pounds) for the entry fee made out to “The Rotary Club of Bedford Benevolent Fund” to  

Ivan Flack, Gobion House, Godfrey Lane, Sharnbrook, Beds. MK44 1PS