Raffle Self-Exclusion Form

By completing and submitting the below form, I am requesting that I be excluded from any form of gambling with St Cuthbert’s Hospice.

Self-Exclusion (Raffle)

Title *

• Mr
• Mrs
• Miss
• Ms
• Other

Name *

First

Last

DOB (DD/MM/YYYY) *

Address *

Postcode *

Email *

Telephone *

I request to be excluded immediately from all of St Cuthbert's Hospice's gambling related activities, including receiving any gambling related marketing materials, for a minimum period of: *Please Select *1 year2 years3 years4 years5 years6 years7 years8 years9 years10 years

Please read and confirm. *

• I acknowledge that I will not be allowed to retract my self-exclusion during this period.
• I acknowledge my responsibility in ensuring adherence to this agreement.
• I acknowledge that St Cuthbert's Hospice, its employees or agents have no liability or claims arising from my voluntary use of the gambling facilities provided.

Submit