Cotswold Care Hospice

Your Details Mens Walk 2012

First Name

Surname

Address 1

Address 2

City

County

Postcode

Date of birth / /

Walking Details

I would like to take part in the:

5 mile walk 10 mile walk

Walk Team Name (if applicable)

Please advise us of any medical conditions and/or dietary requirements you have.

Mobile
We need your contact number on the day of the walk to ensure that we can contact you during the event but won't use this for marketing purposes.

Next of kin (please include contact details)

T-Shirt size:

Small Medium Large Extra Large

How did you hear about Mens Walk?

I understand this walk is not a race and understand that walking along public highways is potentially hazardous. I am aware that the organisers, their employees and their volunteers cannot be held responsible for any personal injury or loss, damage or public liability. I confirm I am in reasonable health and fitness. If under 16, I will be accompanied by an adult.

Data Protection Act. Your details will be held on the Hospice's internal database and will not be sent to any third parties. We like to keep our supporters in touch with our news. Please tick the box if you do not wish to receive communication.

If you are walking for someone special and are happy to be contacted and share your story with us please tick here.

Conditions of Entry

Places are limited and entries are processed in the order we receive them
You cannot register on the day. Closing date for entries is Friday 22nd February 2012
One form must be completed for each person
Please do not send cash in the post
Your place is non-transferable
Your place is non-refundable
Your registration fee covers: secures your place on the walk; the administration of your T-shirt; pie; pint and rugby ticket
Each entrant will be expected to raise further sponsorship
All walkers under 16 must be accompanied by an adult who takes full responsibility for them and must sign a consent form prior to the walk