THE GREAT RADIOTHON RACE
Registration Form

October 18, 2014
9am – Check In
10am – Race Start

  • Please PRINT details below.
  • Registration cost is $40/team of two (2). Each team MUST have exactly 2 members.
  • Completed Registration Form and fee must be received by SEPTEMBER 19, 2014

Make cheques payable to: Wingham and District Hospital Foundation
Mail to: 270 Carling Terrace, PO Box 1228, Wingham, ON, N0G 2W0OR drop them off at the Foundation office in the Hospital.

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):smallmedium 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):smallmedium 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 only for participants 18 and under:

Participant #1 Parent/Guardian Signature: ______

Date: ______

Participant #2 Parent/Guardian Signature: ______
Date: ______

Required:

Participant #1 Signature: ______

Date: ______

Participant #2 Signature: ______
Date: ______

THE GREAT RADIOTHON RACE
Pledge- Instructions

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 PledgeTotal with your teammate’sPersonal PledgeTotal it will give you your Team Pledge Total.It is important to accurately record your personal and team totals. The Personal PledgeTotal will determine how many gifts cards to The Anchor Pub you will receive. Your Team PledgeTotal will determine which team raised the most pledges and earns the “delay another team” advantage.

Want to collect pledges online?Go to and create a GivingPage which is found under heading “How to Give.” Be sure to select Wingham & District Hospital Foundation as your charity. You will then be able to share your page on all your social media and raise even more pledges. Please record each pledge you receive online on your paper pledge form and indicate that the donation was made online. Then record the total amount enclosed with your paper form and the total amount you raised online at the bottom of the pledge form. Add these two totals together to get your Personal Pledge Total. Need help setting up your online GivingPage? Contact Nicole Jutzi at519-357-3210 x 5278 or .
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 519-357-3210 x 5278 or .

THE GREAT RADIOTHON RACE

Pledge Form
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 GivingPage $______

MY PERSONAL PLEDGE TOTAL $ ______TEAM PLEDGE TOTAL AMOUNT $ ______

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