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My name is: ________________________________ and I will be taking part in the Mayor’s Big Shimmy world record attempt on Sunday May 6th, at Thorns Leisure Centre, Brierley Hill. Please can you sponsor me to belly dance continually for 5 minutes? All money raised will support the Mayor of Dudley’s charities: Leukaemia and Lymphoma Research UK and the Soldiers, Sailors, Airmen and Family’s Association (SSAFA).

Name

Address

Postcode

Amount Amount Pledged Paid

Total This form has been stamped to certify that I have taken part in the event and I confirm that all money collected by myself will be forwarded to the event organisers. Signed _____________________

Date _________________

Once sponsorship has been collected cash can be taken to any branch of HSBC making it payable to Mayoral Events. Account number 41708503 Sort Code 12-33-44 If sending a cheque please make it payable to ‘Mayoral Events’ and post to the Mayor’s parlour, the Council House, Dudley DH1 1HF


Sponsorship Form