Moonlight Walk Registration form

Kings Hall, Herne Bay, 8pm, 21 September 2012

Your walk

Which walk do you intend to do?(required)

Registration fee: £15 (under-5s are free).

You can choose to have either a Moonlight Walk t-shirt or a Buff ® scarf (see the Buff ® website for more information on the scarf).

Please tick if you would like to have a Moonlight Walk t-shirt or Buff scarf

Date of birth

If you are under 16, a parental consent form must be completed and brought with you on the day. Under 16s must be accompanied by an adult.

Your date of birth--(required)

Your details

Title

Your title

First name(required)

Surname(required)

Address 1(required)

Address 2

Town or city(required)

County(required)

Postcode(required)

Contact details

Contact tel number(required)

Mobile number

Email address - must be checked regularly (this is the most cost-effective way for us to communicate with you)(required)

Confirm your email address(required)

Pilgrims Hospices is registered under the 1998 Data Protection Act. Your name and address will not be disclosed to any other organisation but we would like, from time to time, to send you news about Pilgrims Hospices and information about our events. Please tick the relevant box/es below if you would like to receive these communications by email and/or by post.

I would like to receive information about Pilgrims Hospices by email

I would like to receive information about Pilgrims Hospices by post

Emergency contact details

Emergency contact name(required)

Emergency contact number(required)

Please advise us of any medical conditions you have

Where did you hear about the Moonlight Walk?(required)

Other place you heard about the Moonlight Walk(required)

Why are you taking part in the Moonlight Walk?(required)

Other reason(required)

Please give your loved one's full name(required)

I have taken part in a Moonlight Walk before

I understand that I take part in the walk at my own risk, that the organisers will provide public liability insurance only and that I am responsible for any personal insurance. I agree to abide by any terms and conditions of the walk as agreed by the organisers. I undertake at all times to behave responsibly and with due care and attention on the route. I agree to follow any and all safety instructions given by the organisers before and during the walk. (Please tick to indicate that you have read and agree to the disclaimer)

Security information

Secured by SagePay

Be assured that payment for your registration will be handled safely and securely online by our payment provider SagePay.