Join us. Get your family, friends and colleagues together in support of Diabetes uK and take part in our 6km wonderful, winter walk around historic Bradgate Park. Entry: £5 per adult. Kids go free!

WintEr WalK

BraDGatE ParK, lEicEstErshirE

sunDay 18 novEmBEr 10.30am

rEGistration formTitle First name

Surname

Address

Postcode

Telephone

Email

I would like a fundraising pack in the post or email .How did you hear about the walk?

If you have an interesting story to tell about your reason for taking part in this event we’d love to hear from you. Please email: midlands@diabetes.org.uk I am happy to share my story with others .

I am happy for Diabetes UK to contact me by email . Diabetes UK takes data protection very seriously. We will not pass your details on to other organisations. If you do not wish to receive further mailings, please tick this box

How many people do you want to register:

Quantity adults – £5 each

Quantity children (under 16 yrs) - free

£ Total

Method of payment I enclose a cheque made payable to Diabetes UK

I would like to pay by Mastercard Barclaycard

Visa Maestro Delta

Card no Valid from / Expiry date /

Issue no (shaded boxes for Maestro only)

Declaration: I confirm I have read the above terms and conditions and I agree to take part in the Diabetes UK Winter Walk on the 18 November 2012.

Print name

Signed Date / /

Please return to: Diabetes UK Midlands, 1 Eldon Court, Eldon Street, Walsall WS1 2JP

You accept that Diabetes UK is not liable for your health and possessions during the event and that you participate at your own risk. All sponsorship raised must be forwarded to the Diabetes UK Midlands office by 13 January 2013. Your photo may be taken by Diabetes UK during the event, any photos will be used for the promotion of Diabetes UK only. Photographs containing your image will not be passed onto third parties. A charity registered in England and Wales (no. 215199) and in

Scotland (no. SC039136). © Diabetes UK 2011