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Registration Form

1. Title *
   
2. First Name *
   
3. Last Name *
   
4. Company/Community Group Name (if applicable)
   
5. Address Line 1 *
   
6. Address Line 2 *
   
7. Postcode *
   
8. Home Telephone Number
   
9. Mobile Telephone Number
   
10. Your Email Address *
    
11. Emergency Contact Name *
    
12. Emergency Contact Number *
    
13. Date of Birth *
    
14. T-Shirt Size:
    Please select a larger size if you plan to wear this over the top of clothing on the night.
    35-37" Small
    38-40" Medium
    41-43" Large
    44-46" X Large
    47-49" XX Large
    
15. Where did you hear about the Midnight Walk?*
    
16. Do you have any medical conditions that we should be aware of? (type no if none)
    
18. Conditions of Entry
    I have read and agree to the rules and conditions for the Midnight Walk 2012. I understand that I take part in this event at my own risk and that St Helena Hospice will not be liable for any injury or loss that may occur as a result of my participation. I confirm that I am over 18 years of age and that my parent/guardian has signed below if I am not. I agree that medical advice should be sought from a General Practitioner if I am in any doubt as to my physical ability to participate in the event. I am aware that photographs taken during the walk may be used to publicise the event and the work of the charity generally and give permission for this.
19. Please remember to check our Rules & Conditions before proceeding.
    
    I agree to the Conditions of Entry and Rules and Conditions of the Walk
    
20. Data Protection
    St Helena Hospice will not share your details with any other organisations. We would like to keep in touch occasionally with news of our work and Fundraising activities. Please tick the box if you would prefer not to be contacted in this way.
    
21. If you are a parent of guardian, please enter your full name below