Ballot place form

Please complete the form below if you have obtained your own place in an event and would like to use your place to raise funds for Spinal Research.

If you have any questions or need any support to complete the form, please contact the events team at events@spinal-research.org.

Your details

First Name

Last Name

Email

Phone number

Address line 1

Town/City

Country

Please select... Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Central African Republic Chad Chile China Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Costa Rica Côte d’Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor (Timor-Leste) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Fiji Finland France Gabon The Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia, Federated States of Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Macedonia Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Sudan, South Suriname Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe

State

Please select... Alaska Alabama Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Province

Please select... Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Nunavut Northwest Territories

Province

Please select... Anhui Fujian Gansu Guangdong Guizhou Hainan Heilongjiang Henan Hubei Hunan Jiangsu Jiangxi Jilin Liaoning Qinghai Shaanxi Shandong Shanxi Shijiazhuang Sichuan Yunnan Zhejiang

County

Please select... Aberdeenshire Angus Antrim Argyll & Bute Armagh Ayrshire Banffshire Bedfordshire Berkshire Berwickshire Blaenau Gwent Borders Bridgend Bristol Buckinghamshire Caerphilly Caithness Cambridgeshire Cardiff Carmarthenshire Ceredigion Cheshire Clackmannanshire Conwy Cornwall County Durham Cumbria Denbighshire Derbyshire Devon Dorset Down Dumfries & Galloway Dunbartonshire East Ayrshire East Dunbartonshire East Lothian East Renfrewshire East Riding of Yorkshire East Sussex Essex Fermanagh Fife Flintshire Gloucestershire Greater London Greater Manchester Gwynedd Hampshire Herefordshire Hertfordshire Highland Inverclyde Isle of Anglesey Isle of Wight Kent Kincardineshire Lanarkshire Lancashire Leicestershire Lincolnshire Londonderry Merseyside Merthyr Tydfil Midlothian Monmouthshire Moray Neath Port Talbot Newport Norfolk North Ayrshire North Lanarkshire North Somerset North Yorkshire Northamptonshire Northumberland Nottinghamshire Orkney Oxfordshire Pembrokeshire Perth & Kinross Powys Renfrewshire Rhondda Cynon Taff Rutland Shetland Shropshire Somerset South Ayrshire South Gloucestershire South Lanarkshire South Yorkshire Staffordshire Stirlingshire Suffolk Surrey Swansea Torfaen Tyne & Wear Tyrone Vale of Glamorgan Warwickshire West Dunbartonshire West Lothian West Midlands West Sussex West Yorkshire Western Isles Wiltshire Worcestershire Wrexham

Zip/Postal code

Date of birth

Event details

What is the name of the event you are participating in?

How much are you hoping to raise in sponsorship?

Your connection to Spinal Research

Connection to Spinal Research

Please select... Family member injured Friend injured I have an injury I've recovered from an SCI Medical professional Reseacher None

Injury level

Please select... Paraplegic Quadraplegic Other

Injury severity

Please select... Complete Incomplete Other

How injury occurred

Please select... Accident at home Medical complications RTA Spinal stroke Sport accident Guillain-Barré syndrome Cauda equina syndrome Other

Year injured

Mobility impairment

Please select... --None-- Manual wheelchair Electric wheelchair Walker

Running top details

T-shirt size

Please select... Extra Small (XS) Small (S) Medium (M) Large (L) X-Large (XL) XX Large (XXL)

Communication preferences

We would love to keep you up to date with all the latest Spinal Research news and information. If you'd like to receive our updates please let us know how you'd prefer to receive them:  

Email

Phone

Text message

By ticking the above boxes and submitting this form, you are agreeing to join our contact lists. We'll only send you information related to Spinal Research. Your privacy is important to us and we process your personal data in accordance with the UK GDPR and our Privacy Policy. You can unsubscribe at any time. For more information about our privacy practices, please visit our website.