Pre-paid
Registration
Form

Complete the registration below to participate in the Empowered Walk. Each person walking, including children, must register separately.

First Name

Last Name

Mobile Number

Street Address

Suburb

State

Postcode

Date of Birth

Emergency Contact Name

Emergency Contact Number

Physically fit

I am physically fit and capable of the 3.5km Walk

Participation Terms and Conditions

I have read and accept the Participation Terms and Conditions