Registration Form – Firewalk Registration is £25 per participant. Please complete one form per participant. 1. Register Title
Surname
Forename
Phone
Address
Postcode
Email*
Mobile* * By giving us your email address and/or mobile number, you agree that we may use it to send you information about our work, fundraising and other activities by email and/or SMS.
2. Are you participating as part of team?
Yes
No
Team Name ___________________Team Leader Name _____________________
3. Payment: CASH Registration Fee
£25
£
CHEQUE £
Cheques to be made payable to Marie Curie
4. Declaration: I confirm that I am fit to take part in this event. I understand the registration fee of £25 is non-refundable and that I am participating in a fundraising event. I understand that photographs may be taken during the event which may be used to publicise future events and the work of the charity generally. Participant’s signature _________________________________ Date_____/ _____/ ____ Thank you so much for registering – your support will make a huge difference to people living with terminal illness. We would like to keep you up to date with details of our work, fundraising activities and ways to get involved. Please choose how you are happy for us to contact you below: I'd like to hear from you by email
I'd like to hear from you by text message
I'd like to hear from you by phone
I'd like to hear from you by post
Please return completed forms to: Fundraising Team, Marie Curie Hospice, Marsh Lane, Solihull, B91 2PQ)
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