THE GREAT HOSPITAL RACE
Registration Form
October 14, 2017
9am – Check In, 10am – Race Start
Registration Fees:
$50/team
**Fees are non-refundable. Entry fee may be transferred to another participant if the original participant in unable to attend.
Complete and return this form to the WDH Foundation office at the Wingham & District Hospital at
270 Carling Terrace or email to [email protected]
Make cheques payable to: Wingham & District Hospital Foundation
Space is limited, so register early to guarantee your spot.
TEAM NAME:
________________________________________________________________________________________
PARTICIPANT #1
Name: ________________________________________Age: ________ Gender (circle): Male / Female
Mailing Address (911 # and PO Box if applicable): ____________________________________________________
_______________________________________________________________________________________
City/Town:______________________________________ Prov.__________ P.Code: ___________________
Email:__________________________________________________________________________________
Telephone/Cell #: ____________________________ T-Shirt Size (circle): small medium large x-large
PARTICIPANT #2
Name: ________________________________________Age: ________ Gender (circle): Male / Female
Mailing Address (911 # and PO Box if applicable): ____________________________________________________
_______________________________________________________________________________________
City/Town:______________________________________ Prov.__________ P.Code: ___________________
Email:__________________________________________________________________________________
Telephone/Cell #: ____________________________ T-Shirt Size (circle): small medium large x-large
I hereby declare I will not hold the Wingham and District Hospital and/or Wingham and District Hospital Foundation responsible liable for any loss, damage, injury or Death
that may occur while in attendance at the event. I accept this risk as my total Responsibility and I fully understand the implication as stated above and in signing assume the
same for dependent children.
As a participant under the age of 18, I understand that I must have this form counter signed by a parent or guardian. As a parent and/or Legal guardian of the above I hereby
give permission for the above named to participate in the Great Radiothon Race on the basis of the conditions set.
Required:
Participant #1 Signature: ____________________________________________________________________
Date: _____________________________
Participant #2 Signature: ____________________________________________________________________
Date: _____________________________
Required only for participants 18 and under:
Participant #1 Parent/Guardian Signature: __________________________________________________________________________
Date: ___________________________________
Participant #2 Parent/Guardian Signature: __________________________________________________________________________
Date: ___________________________________
THE GREAT HOSPITAL RACE
Pledge Instructions
The team that raises the MOST pledges will get to select one other team to be delayed
one minute at the start of the race. Use this power wisely!
Each team who collects $100 - $200 will receive a $10 gift certificate to THE ANCHOR PUB
Each team who collects $200 - $500 will receive a $20 gift certificate to THE ANCHOR PUB
Each team who collects more than $500 will receive a $50 gift certificate to THE ANCHOR PUB
Prizes are generously sponsored by HOWICK MUTUAL INSURANCE COMPANY
***RACE PRIZES!***
1st Place GRAND PRIZE $300!
2nd Place $100
3rd Place $40
There will also be a SPECIAL prize for the team who is the DIRTIEST when they cross the finish line
BRING ALL YOUR PLEDGES WITH YOU ON RACE DAY.
Only pledges presented on race day will count towards pledges prizes.
Print the form below and record the details of each pledge you collect. Full name and address are
important so that a tax-deductible receipt can be sent to the people who pledge your team. Use as many
sheets as you need, but only record the totals on one. The Team Pledge Total on your pledge form and your
teammate’s pledge form should be the same. When you add your Personal Pledge Total with your teammate’s
Personal Pledge Total it will give you your Team Pledge Total. It is important to accurately record your
personal and team totals.
Want to collect pledges online?
1. Go to: https://www.canadahelps.org/en/charities/wingham-and-district-hospital-foundation/greatrace/
and click CREATE A TEAM and follow the prompts to set up your team pledge collection page and share on
social media.
Share your team page using social media to raise even more pledges!
Please record your online total on the paper form and add it to your paper pledges to get your Personal Total.
You do not need to record each individual online pledge on this form. Need help setting up your online
fundraising page? Contact Nicole Jutzi at 519-357-3903 or [email protected].
DON’T FORGET! Bring your form AND all your collected funds on race-day (no “to-be-paid” please).
For any questions or concerns regarding pledges or the Race do not hesitate to contact Foundation
Coordinator, Nicole Jutzi, at 519-357-3903 or [email protected].
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THE GREAT RACE
Pledge Form
All proceeds to upgrade medical equipment at the Wingham & District Hospital
BRING PLEDGE FORM AND PLEDGES ON RACE DAY. YOUR TEAM PLEDGE TOTAL SHOULD MATCH YOUR TEAMMATE’S
CLEARLY PRINT THE NAME AND FULL ADDRESS OF DONORS GIVING $10 OR MORE FOR TAX-RECEIPT PURPOSES
My Name: ____________________________Team Name: ___________________________ Teammate Name: ___________________________
Name
Address
Donation Amount
Total Amount Enclosed with Paper Pledge Form $_______________ Total Amount Raised On Online $____________________
PERSONAL TOTAL $ __________ TEAM TOTAL $ _________
paper pledge form total + online total
Page _______ of _______
teammate 1 personal total [paper+online] +
teammate 2 personal total [paper+online]