Galway Memorial Walk Sunday 9th September 2018 Please complete the form below Galway Memorial Walk Online Registration 2018 All persons, irrespective of age, can participate in the Galway Memorial Walk. Persons aged 18 years and over must register for the event. Persons under the age of 18 years are not required to register for the event.1. Personal DetailsName* First Last Donor CodeIf you have received a Memorial Walk letter, please enter your donor code (eg A1234) as indicated on the top right of your letter.Email* Address* Street Address Address Line 2 City County Postcode / Eircode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Mobile Phone*TelephoneLead ContactIf you are participating as part of a family / group / organisation and there is a lead contact person, please provide his/her name: First Last 2. T-ShirtsPlease choose ONE of the following options in the section below: NONE: I already have a Galway Hospice Memorial Walk T-shirt and will be wearing it again this year. NON-PERSONALISED: I would like a new non-personalised T-shirt with just the Memorial Walk Logo. PERSONALISED: I would like a new personalised T-shirt with the name of the person in whose memory I will be walking. T-Shirt Option*NONENON-PERSONALISEDPERSONALISEDName to be printed on T-Shirt*I’m walking in memory ofConfirm name to be printed on T-Shirt*Please confirm the name to be printed on the T-Shirt to ensure no errors.T-Shirt Size*Please indicate your T-shirt size (Adult sizes only):SmallMediumLargeX-LargeXX-LargeT-Shirt Delivery/Collection*I can have my T-shirt collected from the Hospice (to reduce costs)Please post my T-shirt to me3. Sponsorship CardsSponsorship Cards*How many Sponsorship cards would you like?1Already received sponsorship card.4. Keeping in TouchWe may need to contact you regarding this year’s Galway Memorial Walk. In order for us to communicate with you by phone or email, we need your consent to do so. We would be grateful if you could indicate your preferred method of communication below:Keeping in touch I am happy for you to phone me I am happy for you to email me Please note that you can withdraw these consents at any time by contacting the CEO, Galway Hospice Foundation, FREEPOST, Renmore, Galway H91 2RT. Please also take note that we will retain your details on our Donor Database and we will only contact you with regards to this event in future correspondence.5. DeclarationDECLARATION: I understand that I enter the Galway Memorial Walk at my own risk and that the Galway Hospice Foundation will not be held responsible for any property lost, mislaid or stolen on the route or at any facility area or for any loss or injury sustained by me in the course of the event or in fundraising connected with the event. Furthermore, I hereby grant full permission to Galway Hospice Foundation to use photographs, films or recordings of the event for any legitimate purpose connected with the event and/or with the services of Galway Hospice.Agree to Terms* I agree to Terms above. CAPTCHANameThis field is for validation purposes and should be left unchanged.