Memorial Walk

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


Address


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:



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.


I’m walking in memory of
Please confirm the name to be printed on the T-Shirt to ensure no errors.



Please indicate your T-shirt size (Adult sizes only):

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?



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.