Entry Form

Contact Details

Title *

First Name *

Surname *

Telephone *

Email Address *

Address Line 1 *

Address Line 2 *

Address Line 3

County *

Postcode *

Will you be accompanied?

Yes

If yes, how many people

Did you take part in previous walks?

Yes

If yes, which year(s)

About you

Date of Birth *

Age *

If you have had joint replacement surgery would you mind telling us which joint(s) and the approximate date of your operation.

Name of your Surgeon

Signature

I confirm that to the best of my knowledge I am fit to take part.

I agree *

I consent for my details to be added to The RNOH Charity database so that we can send you regular updates by post.

I consent for my details to be added to The RNOH Charity database so that we can send you regular updates by email.

To anyone 16 and under we need to ask your parent/guardian to confirm they are happy for us to keep information about you on our database.

Please ask your parent/guardian to tick here

You have the right to withdraw consent to receiving information from The RNOH Charity at any time by writing to us stating your details, or by emailing rnoh.fundraising@nhs.net

World-leading specialists need world-leading support.

Entry Form