5k Run/walk Entry Form
Entry Fee: £15 and
Includes a DMH Branded T shirt.

You can fill in the form below and pay securely online.

singing-mincepies


Your Details
Title*
First Name*
Last Name*
Post code*
Address*
Town/City*
Telephone*
std   number 
Mobile
Email*
Date of Birth* dd/mm/yyyy
Under 16?
please tick
If under 16 please state the name of the adult
you will be participating with:
In Memory Of
Who can we contact in
case of emergency?*
Name
Tel
std   number 
How did you hear about this event*

*indicates a required field.
Entry Details
Entry type*
Affiliated Runner
Unaffiliated Runner
Walker
Name of club

Runners
If you are a member of the North Staffs Road Runners please enter your number here

If you are a member of UK Athletics please put your membership number here
Age on
race day*

Dougie Mac
T-shirt size*
(included in entry fee)
Small
Medium
Large
Extra large
Receive Emails

Please tick the box if you do not wish to receive emails about hospice news, events and initiatives.


Online Entry Fee: £15.00
Includes a Dougie Mac T-shirt

Please click the proceed button below to pay for your entry fee

proceed to payments

credit-cards