Name

Telephone Number

Mobile

Email

Date of Birth

T-Shirt Size
8 10 12 14 16 18-20

Group Name

Please note that anyone who took part last year can register for just £12 before 15 March instead of £15. Please tick the box that applies
£12 for people who took part last year  
£15 Registration Fee  

Do you have a special reason for taking part in the Marlborough Starlight Walk?

Would you be happy to be involved in local media coverage about your participation in the Marlborough Starlight Walk?
Yes  
No  

Where did you hear about the Marlborough Starlight Walk?
At Hospice  
Banner  
Club  
Events Booklet  
Facebook  
Poster  
Prospect newsletter  
Publication - Swindon Advertiser  
Publication - Gazette & Herald  
Publication - Handy Mag  
Publication - Link Magazine  
Publication - Wroughton Monthly  
Publication - Other  
Through friend  
Twitter  
Website - Google  
Website - Prospect  
Website - Swindon Advertiser  
Website - Other  
Work  
Other  

We would like to keep in touch with the work and activities of the Hospice. If you would prefer not to receive this information, please tick.
I would prefer not to receive information about other work and activities of the Hospice  

Declaration click here
I have read and accept the declaration  

Billing details:

First Name:

Last Name:

Address 1:

Address 2:

Town:

Postcode:

Email:

Once you complete this form, you will be directed to our secure payment provider to take your payment.