LISTENING EARS ABBEY WOOD WALKATHON CHALLENGE
REGISTRATION FORM 19th MARCH 2011
View full details of this event

Please print clearly and use only one form per person
Title:	Mr Mrs Miss Ms
Full name:
Address:
Address line 2:
Address line 3:
Post code:
Email address:
Date of birth:
Age if under 16 years of age:
If you are under 16 years of age you must run with a registered adult who is participating in their own name and not simply acting as a chaperone.
Name of accompanying adult:
I understand that I take part in this event at my own risk and that Listening Ears cannot be held responsible for any loss, damage or injury, however caused as a result of this activity.
Declaration :	Select I Agree I Disagree (A parent/guardian must sign for any child under 16 years of age)
Donations: I am unable to participate this year but would like to make a donation to Listening Ears.
Your contact details will be automatically added to our mailing list. If you DO NOT want to receive further fundraising information, please tick the box

 

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Company Limited by Guarantee. Registration Number 6227466 (Registered in the United Kingdom)
Registered UK Charity. Charity Registration Number 1145028

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