North West Hospice Memorial Walk October 15th 2017 Please complete the form below (read more about the walk here) North West Hospice Memorial Walk On-line registration 2017 1. Personal Details First Name* Last Name* Email* Address Address Line 1* Address Line 2 City County/State* Post/zip code Country* Select a CountryIrelandUnited StatesUnited KingdomAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCentral African Republic (CAR)ChadChileChinaColombiaComorosDemocratic Republic of the CongoRepublic of the CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorialGuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedonia (FYROM)MadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth KoreaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab Emirates (UAE)UruguayUzbekistanVanuatuVatican City (Holy See)VenezuelaVietnamYemenZambiaZimbabwe Phone Number* Lead Contact If you are participating as part of a family / group / organisation and there is a lead contact person, please provide his/her name: First Name Last Name 2. T-Shirts* Please choose ONE of the following options in this section 1. I would like a personalised Memorial Walk T-shirt with the name of the person in whose memory I will be walking.2. I would like a non-personalised T-shirt with just the Memorial Walk Logo. Name to be printed on T-shirt*I’m walking in memory of Confirm name to be printed on T-Shirt*Please confirm the name to be printed on the T-Shirt to ensure no errors. T-shirt size*Please indicate your T-shirt size (Adult sizes only):SmallMediumLargeX-LargeXX-Large T-Shirt Delivery/Collection* I can have my T-shirt collected from the Hospice (to reduce costs)I can have my t-shirt collected from the Hospice shop in Carrick-on-ShannonPlease post my T-shirt to me 3. Sponsorship Cards How many Sponsorship cards would you like? Sponsorship Cards* 1234Already received sponsorship card. 4. Declaration DECLARATION: I understand that I enter the North West Hospice Memorial Walk at my own risk and that the North West Hospice will not be held responsible for any property lost, mislaid or stolen on the route or at any facility area or for any loss or injury sustained by me in the course of the event or in fundraising connected with the event. Furthermore, I hereby grant full permission to North West Hospice to use photographs, films or recordings of the event for any legitimate purpose connected with the event and/or with the services of North West Hospice. Agree to Terms* I agree to Terms above.