Pendleside Hospice

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LADIES ONLY EVENT

First name:

Surname:

**Please provide your actual home address

Address Line 1:

Address Line 2:

Town:

County:

Postcode:

Daytime Telephone Number:		Evening Telephone Number:

Mobile Telephone Number:		Email Address:

T-Shirt Sizes:

Please choose the size of your Midnight Walk T-Shirt

Date of Birth:

You need to be 11 years of age to take part in the Midnight Walk. If you are under 16 years of age please ensure you specifiy a parent or guardian name below. Walkers between the age of 11-16 must be accompanied by an adult also registered on the walk.

Under the age of 16:

Name of accompanying adult:

If you are walking as part of an organised group please put your group name here:

I would like to complete :

Food Option:

If you know a male willing to volunteer on the evening please give his details:

Volunteer Name:

Volunteer Telephone:

Volunteer Address

Terms and Conditions

Contact the Fundraising team direct on 01282 440120
Email fundraising@pendleside.org.uk

Get in touch