STEH Halloween firewalk form AW - St Elizabeth Hospice

Make each
day count
Saturday 30th October 2010
Greshams Sports and Social Club,
Tuddenham Road, Ipswich
firewalk
Halloween
Fearless fundraisers are offered the ultimate
challenge, walking between 15-20ft over
hot coals at 550 degrees celsius! Perform
this unique mind-over-matter experience
following expert tuition from Guinness
World Record Holder Scott Bell.
Bring along your friends and family
to join in the Halloween fun!
www.stelizabethhospice.org.uk

Halloween
Firewalk
entry
form
Scott Bell is the twice Guinness World Record holder
for the ‘Greatest Fire Walking Distance’ by walking
328 feet on burning coals. You will undergo a one
hour seminar from Scott in which he will explain the
history of firewalking and the technique behind it.
Then, to the beat of the drum it will be time for you
to take up the challenge.
Register now as this is a popular event and places
are limited! Registration is £30 per person and we
ask you to raise a minimum of £100 in sponsorship.
Participants must be 16yrs old and over.
There will also be a Halloween party during this
event and spectators are welcome to come along
and join in the fun. Tickets are £5, under 16yrs free.
The Halloween party begins at 6pm and the seminar
will start at 7pm followed by the firewalk at 8pm.
To register, please complete this form and return
to the address below. We will then send you a
sponsorship pack, including guidelines and
further information.
For more information or to buy tickets to the
Halloween Party, call 01473 723600, email
fundraising@stelizabethhospice.org.uk or
visit www.stelizabethhospice.org.uk
Please complete one registration form
per person in BLOCK CAPITALS
■ Mr ■ Mrs ■ Ms ■ Miss ■ Other:
First name:
Last name:
Address:
Postcode:
Date of birth:
Telephone:
Mobile:
Email:
Emergency contact
(this should not be someone taking part in the event)
Name:
Telephone:
How did you hear about the Halloween Firewalk?
Do you have a special reason for taking part?
Entry fee
Registration is £30 per person and we ask you raise a
minimum of £100 in sponsorship.
All entry fees are non-refundable.
■ I enclose a cheque for £........ payable to St Elizabeth Hospice
■ Please debit £........ from my:
■ Visa ■ Mastercard ■ Maestro ■ Other
Card number:
■■■■■■■■■■■■■■■■■■■
Valid from: ■■ /■■
Expiry date: ■■ /■■
Issue number: ■■ (Maestro only)
Cardholder’s signature:
Date:
If paying by debit/credit card we will telephone you
for the security code on the reverse of your card.
Terms and conditions
*I, the undersigned, (on behalf of any other mentioned persons) wish to take part in
this event. I understand that this is done at my/our own risk and absolve St Elizabeth
Hospice from any injury caused through participation in this event.
Signature*:
Date:
*If under 18, this must be from your parent/guardian.
We would like to keep you up to date with news and fundraising activities.
If you would prefer not to receive this information, please tick here ■
Please return your completed entry form to:
Fundraising team, St Elizabeth Hospice,
565 Foxhall Road, Ipswich, IP3 8LX
(Maestro only)
t 01473 723600 f 01473 274717
e fundraising@stelizabethhospice.org.uk
w www.stelizabethhospice.org.uk