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Email *

Tick if you are happy for us to use your email to keep you up-to-date on NRH Foundation activities and how fundraisers like you are making a difference to the NRH, through our electronic newsletter. *

Yes

No

Full Name *

Address 1 *

Town / City *

County *

Eircode *

T-Size *

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Large

X-Large

XX-Large

XXX-Large

Are you taking part as an individual or part of a group? *

Individual

Group

Are you registered with Hell & Back? *

Yes

Not yet

You must register on www.HellAndBack.ie in order to secure entry for the event.

How did you hear about the NRH Foundation? *

Patient

Patient Family

Patient Friend

Previous Participant

NRH Foundation Website

Hospital Posters

Email / Ezine

Word of Mouth

Other

Why are you taking part for the NRH Foundation? *

Have you set up you online fundraising page? *

Yes

Not Yet

To set up your very own online fundraising page go to the drop down menu on our website and select "Get Involved" > "Start Fundraising" > "Set up a fundraising page" and click the green "Fundraise" button. After you set up your Fundraising Page for the 20

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