^ East Lancashire Hosprice invites ............ ■" >L i fe -
TARLIQHTW ■■ersonai Information
Title First Name
Home Address Tel No
Surname Postcode
Emai
Age ■ : ■ ■- .■ You need to be 10 years of age or older to take pan !i' of age please ensure your parent or guardian sigirs ■'
How did you hear about the walk?
T-Shirts Size: Child □ Small (8-10) G Medium i l 2 - 10)
Additional Information Please advise of any dietary requirements: Please advise of any medical conditions:
If you know anyone who may be v/illmg to '.'Olunteer on me n.g' Name
Tel No
Email Payment Details
I wish to pay my entry fee by: Cheque □ Card type: Mastercard □ Visa □ Switch Maestro □ Card number
I
Start date d i n / O i _ I Expiry date!____!!____ Issue number i__^i__ Security number L E IO ^ ■ : ■
^1 II i‘ ]!_ _ _ _ _ ■
Name on card Cardholder's address ■; ■■■■
Postcode : o K v r Signed
By signing the form. I confirim that I have read and accept the conditions of entw to the Starlight Walk and the rules and conditions of this event. Entry' forms that are not signed will be returned.
Your details will be held in the East Lancashire Hospice database and vull not be sent on to_any third parties. If you do not wish to be kept updated about Hospice news, please tick here l_J Please return to: Denise Gee, East Lancashire Hospice, Park Lee Rd, Blackburn BB2 SHY OFFICIAL USE ONLY: Date received
Date cent sent Donor No. fZ}._ _ I Large 115 i_ X-Lame
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