Name *

• Miss
• Mrs
• Ms
• Mr

First Name *

Surname *

Address *

Post Code *

Daytime Tel No *

Date of Birth *

Email *

Emergency Contact Name *

Emergency Contact No *

Name of Guardian *

I agree to the above taking part *

• I agree to the above taking part

Please tick if you would like the vegetarian option

• Please tick if you would like the vegetarian option

Please let us know why you are taking part in the Moonlight Walk

Would you be prepared for us to use your story in future publications? *

• Yes
• No

I have entered the Moonlight walk entirely at my own risk and will abide by the walking instructions made by the organisers and I understand that St Barnabas cannot accept any liability for any injury I might sustain or any property I may lose or damage d *

• Please tick to confirm acceptance

Date *

I am registering for the following St Barnabas Hospice Moonlight Walk *

• Lincoln 16th June 2012
• Louth & Skegness 30th June 2012
• Grantham 7th July 2012
• Market Deeping 14th July 2012

How did you hear about the event? (Tick appropriate one)

• Radio Advert
• Banner in local area
• Leaflet in the mail
• St Barnabas Newsletter
• Local paper
• Recommended by Friend/Family
• Word of mouth
• Other

If you heard about us from a local paper please state which…

If you heard about us from another source please state where… *

* Required Fields