Fundraise for us

Yes, I give permission to store and process my data *

Consent for storing submitted data. See our Privacy and Cookies Policy

Title

Name *

What is your age group? *

16–29

30–45

46–59

60–79

80+

Address *

Telephone Number *

Email Address *

Preferred Method of Contact

Telephone

Email

Is your Event

My own event

An organised event

Venue for Event *

Date of Event *

Tell us about your Fundraising *

Do you have a target amount?

Do you have a specific ward or department you'd like to benefit?

Are you happy to take part in promotional filming as part of your fundraising?

Yes

No

Are you raising funds for any other charity or cause? If yes, please state who and what percentage they will receive.

How are you raising money for us?

Donating all the money raised and collected

Donating the profits from my event

Donating the proceeds of a raffle

Other

I am happy for UHNM Charity to use my photos and videos to promote my fundraising via

Social Media (Facebook, Twitter, Instagram)

UHNM Charity Website Hospital Publications

External Media

I commit to donate a minimum of £100 to receive a free charity t-shirt

Yes

Do you require any collection buckets for your event? If so, how many?

I understand and agree to donate the proceeds of my Fundraising Event/Activity to University Hospitals of North Midlands Charity within 4 weeks of the event date. *

Under no circumstances will I divert any money raised in this name to any other organisation or individual, without the full knowledge and consent of University Hospitals of North Midlands Charity.

The University Hospitals of North Midlands Charity does not accept any responsibility for my Fundraising Event *

I understand and agree that University Hospitals of North Midlands Charity does not accept any responsibility for my Fundraising Event. I understand and agree that I am undertaking this event or activity at my own risk and that University Hospitals of North Midlands Charity is not responsible for any risk, injury, loss or damage that may result and will not be liable for any claim which may arise.

I will provide a full report *

I understand and agree that when I give my donation to University Hospitals of North Midlands Charity, I will give them my sponsorship forms I have used to collect the money (or if I have paid for any costs from the money raised, I will provide a full report listing the money raised, all expenditure (with receipts) paid and the value left over that I am donating.

Have you read the guidance? *

If you are a UHNM member of staff holding a fundraising event, I have read the guidance for staff holding a fundraising event.

Signature *

Date *

How did you hear about us?

Facebook

X

Instagram

Local Media

Word of Mouth

UHNM Publication

Other

Let's keep in touch!

Yes

No

Fundraise for us

Tell us about you!

Tell us about your event!

Promoting your Event

Your Declaration

Royal Stoke University Hospital

County Hospital

Contact us

Tracking

Third Party Embeds