Title:

First name:

Surname:

Address 1:

Address 2:

Town/City:

Postcode:

Daytime telephone:

E-mail:

Do you have any dietary needs?

Chosen route:

Where did you hear about this event?

T-shirt size:

I understand that this walk is not a race and understand that walking along public roadways at night is potentially hazardous. I am aware that the organisers and their employees and volunteers cannot be held responsible for any potential injury, accident, loss, damage or public liability. I can confirm I am in reasonable health and fitness. If under 16 I will be accompanied by a responsible adult.

Signed:

Date: