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REGISTRATION FORM |
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Neville Taylor I hereby confirm that I wish to take part in "Walk the Test Way" on Sunday 12th October 2008. I enclose a cheque for £5.00 made payable to the "Rotary Club of Romsey Test". I confirm that I will raise sponsorship in support of the charity I specify below. I will collect and forward these to the Rotary Club within 3 weeks after the event. It is accepted that I participate in the walk of my own free choice and do so entirely at my own risk. I also confirm that the Rotary Club of Romsey Test are not liable in the event of any accident. |
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* Boxes marked with an asterisk must be filled in |
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| Title: | * | |
| Forename: | * | |
| Surname: | * | |
| Address 1: | * | |
| Address 2: | ||
| Town: | ||
| County: | ||
| Post Code: | * | |
| Telephone: | ||
| Mobile: | ||
| Which Charity do you want to support: | *Rotary Supported Charities/ Other (Delete as applicable) | |
| Details of Other Charity (if applicable): | ||
| Are you over 14 on the 8 Oct 2006: | *YES
/ NO - Delete as Applicable If NO please ask a parent/guardian to fill the part below in: |
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| As the parent/guardian, please state your name and confirm that you hereby agree with the above details and also to the above named participating in the Walk: | Parent / Guardian Name: | |
| Name of accompanying adult who must also register separately: | ||
| I Agree: YES / NO - Delete as applicable | ||
| Do you have any medical condition or disabilities that we should be aware of (please give details)? | ||
| I wish to start my walk from: | *
Please delete as applicable:
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| Where did you hear about the walk? | * Charity / Friend-Contact /Vendor Cup/Leaflet / Newspaper/ Another Website / Poster / Other (please provide details) - delete as applicable | |
| Details where heard (if appropriate): | ||
| Any other points you would like to make: |
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AFTER COMPLETING FORM PLEASE POST TO NEVILLE TAYLOR - ADDRESS ABOVE |
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Rotary Club of Romsey Test is a Registered Charity - No: 1029525 |
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