Your name

Your address (line 1)

Your address (line 2)

Town

Postcode

Telephone number

Your email address

Description of your event

Your event date

Declaration:
I agree to donate all the proceeds from the above event to Birmingham Children's Hospital Charities. 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 Birmingham Children's Hospital Charities.