Galway Memorial Walk 10th September 2017 Please complete the form below Galway Memorial Walk On-line Registration 2017 1. Personal DetailsName* First Last Email* Address* Street Address Address Line 2 City County ZIP / Postal Code 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 Country Mobile Phone*Telephone*Lead 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 this sectionT-Shirt Option*1. I already have a Galway Hospice Memorial Walk T-shirt and will be wearing it again this year.2. I would like a new personalised T-shirt with the name of the person in whose memory I will be walking3. I would like a new non-personalised T-shirt with just the Memorial Walk Logo.Name 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*SmallMediumLargeX-LargeXX-LargePlease indicate your T-shirt size (Adult sizes only):T-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?123456789Already received sponsorship card.4. 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.