How Can We Help?

Title

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Last Name

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Date of Birth

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Preferred Contact Tel No

Email

Have you previously received a grant from Challenging MND?

Yes

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Date / Time

Please provide details of the event:

Are you completeing the application on behalf of the person above?

Yes

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Title

First Name

Gender

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Preferred Contact Tel No

Email

Relationship to person above

Has the person with MND consented to this application and the sharing of their personal information?

Yes

No

Details of Request

If known, what costs will be involved?

I confirm the details I have given on this form are true and accurate and agree that details of this application may be shared with others involved in supporting the event/challenge.

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I consent to having this website store my submitted information and I am happy to be kept up to date with future news and events from Challenging MNDonly. Please note: your details WILL NOT be passed onto any other 3rd parties.

In order to prevent any fraudulent claims, we require you to send us proof of diagnosis with any application.

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Natalie's Story

Matterhorn Climb 2019