Individual and Team Leader Entry Form - Step 1

You can register online for the Goodnight Walk. You must be over 16 years of age and in possession of a valid credit or debit card. Payment can be made securely via Sagepay, our secure payments service. Please fill in the form below.

Fields marked * are mandatory

Title * Mrs / Miss / Ms / Mr / Other

First Name *

Last Name *

Address line 1 * (This should be the address to which your credit card is registered)

Address line 2

Post Town *

Post Code *

Email Address *

Yes, I would like to keep in touch with IRGH via email and hear about future events, activities and appeals.

Phone Number (home) *

Phone Number (work)

Emergency Contact Name*

Emergency Contact Number *

T Shirt Size *

Where did you hear about the Goodnight Walk?*

What inspired you to take part?

Are you walking in memory of someone?

DATA PROTECTION

The information you enter here will be processed by Sagepay, the secure online payment processing company. We do not retain any of your payment details, although we will add your contact details to our database. We promise to protect your privacy and will not share your details with other organisations. All information you give us is managed in accordance with the Data Protection Act (1988). We would like to keep you informed about our work; however, if you prefer not to receive such information please call the Fundraising Team on 01442 890222.

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