Memory Walk & Jog

First Name *

Last Name *

Email Address *

Phone Number *

DOB *

Month *

Year *

Gender *

Male Female Other

Organisation Name

Unit Number

Street Number

Street *

City *

Postcode *

State *

Country *

Reason for organising event *

Proposed Date *

Proposed Time *

Proposed location *

Will you sell tickets?

How many people might attend? *

Please specify the ticket names and prices

How much do you want to raise for Dementia Australia? *

Name of local council where event will be held *

Has the local council already approved the event? *

Will you have any entertainment or food and drinks stalls? *

If yes, please specify

Please provide a brief description of your event

Beat dementia, MyWay.