Your details

• Title Please select Mr Mrs Miss Ms Dr
• First Name *
• Last Name *

• Address 1 *
• Address 2
• Address 3
• Town *
• County
• Country
• Postcode *

• Home Phone
• Mobile Number

  By providing your mobile phone number above, you understand that we may contact you by SMS in relation to this event. In order for us to communicate with you via SMS, your number will be passed to a third party company who will act on our behalf. No other details will be passed on and your information will not be used to contact you for any other purpose. If you would prefer not to receive updates via SMS or change your mind in the future, please contact us on: 01484 557911 or email: events@kirkwoodhospice.co.uk. Please note that we may continue to contact you about this event via SMS in case of emergency.

• Email *

  By providing your email address above you understand that we may email you in relation to this event. In order for us to communicate with you via email, your name and email address will be passed to a third party company who will act on our behalf. No other details will be passed on and your information will not be used to contact you for any other purpose. If you would prefer not to receive updates via email or change your mind in the future, please contact us on: 01484 557911 or email: events@kirkwoodhospice.co.uk. Please note that we may continue to contact you about this event via email in case of emergency.

• Taking Part With Please Select Family Friends A Company A Club Alone
• Share your story

  Please tick here if you would like to share with us why you are taking part. If ticked, a member of the team may contact you regarding your story.

  Yes

Register additional people?

• Would you like to register additional people? No extra people 1 2 3 4 5 6 7 8 9
• Team Name

Additional participant 1 details

• Title Please select Mr Mrs Miss Ms Dr
• First Name
• Last Name

• Under 16?
   Yes

  Please note that all entrants aged 16 and under must be accompanied by an adult who is a registered participant.

• Name of accompanying registered participant (if participant is under 16)

• Address 1
• Address 2
• Address 3
• Town
• County
• Country
• Postcode

• Home Phone
• Mobile Number
• Email

Additional participant 2 details

• Title Please select Mr Mrs Miss Ms Dr
• First Name
• Last Name

• Under 16?
   Yes

  Please note that all entrants aged 16 and under must be accompanied by an adult who is a registered participant.

• Name of accompanying registered participant (if participant is under 16)

• Address 1
• Address 2
• Address 3
• Town
• County
• Country
• Postcode

• Home Phone
• Mobile Number
• Email

Additional participant 3 details

• Title Please select Mr Mrs Miss Ms Dr
• First Name
• Last Name

• Under 16?
   Yes

  Please note that all entrants aged 16 and under must be accompanied by an adult who is a registered participant.

• Name of accompanying registered participant (if participant is under 16)

• Address 1
• Address 2
• Address 3
• Town
• County
• Country
• Postcode

• Home Phone
• Mobile Number
• Email

Additional participant 4 details

• Title Please select Mr Mrs Miss Ms Dr
• First Name
• Last Name

• Under 16?
   Yes

  Please note that all entrants aged 16 and under must be accompanied by an adult who is a registered participant.

• Name of accompanying registered participant (if participant is under 16)

• Address 1
• Address 2
• Address 3
• Town
• County
• Country
• Postcode

• Home Phone
• Mobile Number
• Email

Additional participant 5 details

• Title Please select Mr Mrs Miss Ms Dr
• First Name
• Last Name

• Under 16?
   Yes

  Please note that all entrants aged 16 and under must be accompanied by an adult who is a registered participant.

• Name of accompanying registered participant (if participant is under 16)

• Address 1
• Address 2
• Address 3
• Town
• County
• Country
• Postcode

• Home Phone
• Mobile Number
• Email

Additional participant 6 details

• Title Please select Mr Mrs Miss Ms Dr
• First Name
• Last Name

• Under 16?
   Yes

  Please note that all entrants aged 16 and under must be accompanied by an adult who is a registered participant.

• Name of accompanying registered participant (if participant is under 16)

• Address 1
• Address 2
• Address 3
• Town
• County
• Country
• Postcode

• Home Phone
• Mobile Number
• Email

Additional participant 7 details

• Title Please select Mr Mrs Miss Ms Dr
• First Name
• Last Name

• Under 16?
   Yes

  Please note that all entrants aged 16 and under must be accompanied by an adult who is a registered participant.

• Name of accompanying registered participant (if participant is under 16)

• Address 1
• Address 2
• Address 3
• Town
• County
• Country
• Postcode

• Home Phone
• Mobile Number
• Email

Additional participant 8 details

• Title Please select Mr Mrs Miss Ms Dr
• First Name
• Last Name

• Under 16?
   Yes

  Please note that all entrants aged 16 and under must be accompanied by an adult who is a registered participant.

• Name of accompanying registered participant (if participant is under 16)

• Address 1
• Address 2
• Address 3
• Town
• County
• Country
• Postcode

• Home Phone
• Mobile Number
• Email

Additional participant 9 details

• Title Please select Mr Mrs Miss Ms Dr
• First Name
• Last Name

• Under 16?
   Yes

  Please note that all entrants aged 16 and under must be accompanied by an adult who is a registered participant.

• Name of accompanying registered participant (if participant is under 16)

• Address 1
• Address 2
• Address 3
• Town
• County
• Country
• Postcode

• Home Phone
• Mobile Number
• Email

Gift Aid

• Yes, I want to Gift Aid my donation and any future donations I make to Kirkwood Hospice.

Declaration

• Accept Declaration * Yes

Help us with our marketing in the future

• How did you hear about us Please select Pulse Radio Advert Facebook Twitter Instagram Huddersfield Examiner Dewsbury Reporter Series At Kirkwood Hospice Kirkwood Hospice Shop Kirkwood Hospice website Poster 50 Plus Magazine My Community News HD Life Mirfield Word Word of Mouth Previous Participant Other (Please state below)
• How did you hear, if other

Keeping in touch

Your support makes a big difference to families in your local community, improving their quality of life every single day. We’d really like to keep in touch about our work and how your help Supports Life across Kirklees. if you select 'Yes' below we’ll sign you up to our mailing list. We won't bombard you with emails. Instead, we'll send you our monthly eNewsletter and the occasional extra bulletin when we've something special to share about the care we offer or how you can get involved. You can unsubscribe at any time.

• May we contact you by email?* Please select Yes, please email me No thanks

Your communication preferences

The Kirkwood will collect a limited amount of data from you if you choose to sign up for our newsletter, register for an event, fundraise, make a donation or take part in our lottery. We will only use your information to provide you with information or updates that we believe are relevant to you. You can let us know at any time if you would prefer not to receive information from us anymore. Simply contact us on: 01484 557 911 or email: events@thekirkwood.org.uk

If you would like to receive information from us in other ways please tell us at www.thekirkwood.org.uk/preferences