Galway Memorial Walk Sunday 8th September 2019 Please complete the form below Galway Memorial Walk Online Registration 2019 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 AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe 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 TouchIn order for us to communication with you by phone or email regarding Galway Hospice News including details of the Galway Memorial Walk, 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 Your information is of the utmost concern to us. We undertake to never share your details with any other organisation or third party. Your marketing consents or preferences can be changed at any time by calling 091 770868 or email firstname.lastname@example.org or by writing to us. You will be given the opportunity to withdraw your consent preference for all future communications.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. CAPTCHAEmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.