MNDA East Kent - Coastal Walk to D'Feet MND Entry Form

Please complete the form below to register for the walk, please ensure you state the length of walk, an emergency contact and phone number.
Please enter a medical note if there is something we should know in case of emergency.
Please ensure all fields marked with a blue background are completed. If you cannot complete any field please enter None.

First Name * :

Last Name * :

Address:

Town/County/Postcode:

Telephone Home:

Telephone Work:

Telephone Mobile * :

Email Address * :

Emergency Name * :

Emergency phone * :

Walk Length * :

T Shirt Size * :

Medical note: