WALK 500 MILES CHALLENGE

REGISTRATION FORM

Name: ____________________________________________ Address: ___________________________________________ ___________________________________________ ___________________________________________ Contact Tel No: ______________________________________ Date of Birth: _______________________________________

MALE □ FEMALE □

Please list any special requirements or health issues you may have:

Please return this form to: Lorraine Gillies, Health Promotion, NHS Western Isles, 37 South Beach, Stornoway, HS1 2BB. For an electronic copy of the form please email: lorraine.gillies1@nhs.net, or visit www.promotionswi.scot.nhs.uk For further information contact: Chris Ryan, 01851 702712, chris.ryan1@nhs.net

WALK ON HEBRIDES