Do something amazing and sign up for The Myton Hospices Fire or Ice Walk today! "*" indicates required fields Step 1 of 2 0% Unique IDYour ticket... Which would you like to take on? Fire Walk - £25 - minimum sponsorship £100 Ice Walk - £25 - minimum sponsorship £100 Fire and Ice Walk - £40 - minimum sponsorship £150 Please select your FREE completion t-shirt size* 12-13 years S M L XL XXL XXXL Are you over 18?* Yes No Are you over 12?* Yes No We are incredibly sorry but you have to be over the age of 12 to take part in this event. Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please let us know the name of the responsible adult who will be with you on the evening*Your responsible adult does not have to take part in this event Your details... Title* Mr Mrs Miss Ms Dr First name* Surname* Email* Mobile number* Your address... Please enter your postcode and select your address* Address line 1* Address line 2 Address line 3 City / Town* County Postcode* Country*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsBilling State***Please select a state**ALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWYIs your payment information the same as your participant details entered above?* Yes No Please enter the details which are registered to the credit or debit card you will use to pay... First name* Surname* Address line 1* Address line 2 City / Town* Postcode* Your fundraising... With your help and support, we want to raise £25,000 from this event so we can continue to provide our services free of charge to people with life-limiting illnesses, and their families, now and in the future. Everyone who takes part will not only receive a bespoke completion t-shirt, a completion mug and certificate but FREE entry to The Rugby Fireworks display. Pledge* I pledge to raise a minimum of £100 in sponsorship to take part in this event Pledge* I pledge to raise a minimum of £150 in sponsorship to take part in this event Your welcome pack*If you are able to download your welcome pack and/or print it yourself we would really appreciate it, this will save us a considerable amount of money on printing and postage as each pack costs around £3. We are also trying to ensure our events are as environmentally friendly as possible and cut down on unwanted waste so would appreciate your support with this. I am happy to download my welcome pack Please post my welcome pack to me at the estimated cost of £3 per pack to Myton If you would like a Myton T-shirt please click on the options below... T-shirt Forever in our Hearts T-shirt with your loved ones name and photo - £15 Forever in our Hearts T-shirt with your loved ones name - £12 Myton Branded T-shirt - £5 No T-shirt thank you HiddenT-shirt 01 HiddenT-shirt 03 HiddenT-shirt 06 HiddenT-shirt 05 HiddenTSHIRT Please select your size* S M L XL XXL Your loved ones name to be printed on the t-shirt* Upload an image of your loved one to be printed on the t-shirt*The maximum file size you can upload is 5MB for anything larger than this please email events@mytonhospice.org with your contact details and the photo. Drop files here or Select files Accepted file types: jpg, jpeg, png, bmp, heif, hevc, Max. file size: 5 MB. Why are you supporting Myton? Why are you supporting Myton?*You can select multiple In memory Thanks for care Hospice movement Local charity Other Please let us know the first name of your loved one* Please let us know the surname of your loved one* Please let us know their relationship to you* Please let us know why* Where did you hear about this event?*You can select multiple Email Facebook Flyer Flyer through my door Friends, family or word of mouth Instagram Leam Food & Drink Festival flyer LinkedIn Myton's website Newspaper / Magazine Other Other website Poster Roadside banner Twitter Please tell us where* Please select your amountIf you have clicked an amount by mistake you can enter "0" if you wish not to add a donation... Please select one of the below Yes claim Gift Aid for the last four years /and any I may make in the future, until I notify you otherwise Yes claim Gift Aid for my latest donation /and any I may make in the future, until I notify you otherwise I am NOT a UK taxpayer or do not wish to Gift Aid my donations HiddenGA Date Four Years HiddenGA Date today DD slash MM slash YYYY HiddenGA No Date DD slash MM slash YYYY Find out the difference your support makes... Thank you for your support and interest in Myton. We are determined to keep providing compassionate palliative and end of life care free of charge. You are really important to us and we would love to keep you updated about the impact your support has, as well as news and activities that may interest you. Would you like to hear from us by: By email* Yes No By text* Yes No Event Registrations T&C's... Contact details provided (including email address and telephone number) are used to keep you up to date about the event you are taking part in and support you in your fundraising efforts where appropriate All details will be stored securely and are used in relation to the event you are taking part in. Please ensure that you read a full copy of our terms and conditions for this event by clicking here. Your privacy... We promise to do our best to keep your details safe and secure and will only process your data in accordance with the current Data Protection legislation. Our Privacy Policy explains how we keep this promise and you can read more online at www.mytonhospice.org/privacy-policy If you change your mind about hearing from us please email DSCT@mytonhospice.org or call us on 01926 358383. I have read and accept The Myton Hospices Terms and Conditions for this event.* I accept I have read and accept The Myton Hospices Privacy Policy* I accept Total HiddenFIRE HiddenICE HiddenBOTH HiddenTICKET HiddenDON
