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State Street Caledonian Challenge
The Scottish Community Foundation
126 Canongate
Edinburgh EH8 8DD

Name of marshal: (please print)

Position held during Challenge Check point / or Water Stop:

Name of charity nominated:
a)
b)
c)

Sum out of a total of £150 to be donated:
a)
b)
c)

Address /or contact details: (if known)
a)
b)
c)

If further space is required, please continue overleaf -

Signature of claimant:

Address of claimant:

Official use only

Payment authorised by:

Date: