Midnight Saturday 16 May 2015 EASTBOURNE Together we can make every day count for every child being cared for by Chestnut Tree House. Register now to walk 4 or 10 miles with us. www.nighttoremember.org.uk/cth or call 01903 706354 Early bird discount offer ends 14 March 2015 Find us on Facebook Twitter #CTHN2R REGISTRATION FORM TITLE NAME AGE TEAM/COMPANY NAME TEAM LEADER HOME ADDRESS POSTCODE HOME TEL MOBILE This is essential for communications on the night EMAIL By providing us with your email address you are giving us permission to contact you via email 10mile WouldyoulikeaJustGivingpagecreatedforyou? Y Routelength 4mile T-SHIRT SIZE S M L N How did you hear about Night to Remember? HospiceFundraiser�� Facebook�� Hospicenewsletter�� Telephonecall�� Email�� Wordofmouth�� Takenpartbefore�� Searchengine�� Radio–Whichstation? XL DIETARY REQUIREMENTS I AM TAKING PART IN MEMORY OF: Some of our walkers take part in memory of a loved one, please skip this question if it does not apply CouldyoubeaSuperstar? Banner–Wheredidyouseeit? Superstarsaremidnightwalkambassadors,givingtheirtimetorecruit friends,familyandvolunteerstotakepart�Allsuperstarswillbegiventhe materials,supportandadvicetohelpmakearealdifference�Oncompletion ofyourrolewewillprovideyouwithaspecialSuperstarhoodietowearon thenight�Ifyouwouldliketoknowmorepleasetickhere Superstar-Whichsuperstar? Flyer/poster-Wheredidyouseeit? Otherpleasespecify I ENCLOSE A CHEQUE FOR £20 (£15 before 14 March) (made payable to Chestnut Tree House) PLEASE DEBIT MY CREDIT/DEBIT CARD £20 (£15 before 14 March) Cardtype: (wecannotacceptAmexorDinersClub) Cardholder’sname: Validfrom: Cardnumber Expirydate: 3-digitsecuritynumber: Issuenumber(Maestroonly): Signature: ENTRY INFORMATION Oneformmustbecompletedperentrant Registrationfeesarenon-refundable Entryfeeis£20perperson,thisincludesyourfundraisingpack,t-shirt, torch,medalandbreakfast) Allwalkersareexpectedtoraisefurthersponsorship Allwalkersmustbefemaleovertheageof16 £15 early bird offer only valid until 14 March 2015 AllentryformsmustbereturnedbyFriday1May2015 Date: CONDITIONS OF ENTRY I understand that this walk is not a race and that walking along public roadways at night is potentially hazardous. I acknowledge that all walkers enter this event at their own risk and that Chestnut Tree House is not liable for any injury or loss that may occur as a result of participation. I understand that walkers should take medical advice if in any doubt of their physical ability to take part in this event. Your details will be held on our database and not passed on to any third parties. If you would prefer not to receive any future mailings from us, please call the database administrator on 01903 706327 We need lots of volunteers on the night – if you know someone who can help, please tick this box PLEASE RETURN THIS FORM TO: Freepost RSLL-CHXE-CGZR, Chestnut Tree House Events Team, 2 Titnore Lane, Worthing, BN12 6NZ Telephone 01903 706354 www.nighttoremember.org.uk/cth