Back Up Wheelchair Challenge

Apply below

Title

First Name *

Surname *

Address

Address Line 1 Address Line 2 Town County Postcode

Phone

Email *

Enter Email Confirm Email

Which option would you like to choose? *

Option 1: £50 registration fee, £100 minimum fundraising. This will include wheelchair hire (from a registered supplier), delivery and pick up as well as a fundraising pack
Option 2: No registration fee and you set your own target

What date would you like to do the challenge? *

Why have you decided to take on the Wheelchair Challenge?