The Great Hospital Race Registration

Team Information

Quantity
Price
Total
Team Registration (2people)

Quantity = 1. To register more than one team please complete the form separately for each team. ($60 registration + $1.61 processing fee)

X
$
51.61=
$
0
Team Name
Racer #1 Name
Racer # 1 Age
Racer #1 Disclaimer
  • Yes, I hereby declare I will not hold the Wingham & District Hospital and/or Wingham & District Hospital Foundation responsibly 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 accepting assume the same for dependent children.
 
 
 
 

Participants under the age of 18 must have this form counter signed (accepted) by a parent or guardian.

Racer #1 Parent/Guardian Disclaimer
  • Yes, as a parent and/or Legal guardian of the above I hereby give permission for the above named to participate in the Great Hospital Race on the basis of the conditions set.
 
 
Racer # 1 Parent/ Guardian Name

 

 

Racer #2 Name
Racer #2 Age
Racer # 2 Disclaimer
  • Yes, 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.
 
 
 
 

Participants under the age of 18  must have this form counter signed (accepted) by a parent or guardian.

Racer #2 Parent/Guardian Disclaimer
  • Yes, as a parent and/or Legal guardian of the above I hereby give permission for the above named to participate in the Great Hospital Race on the basis of the conditions set.
 
 
Racer #2 Parent/Guardian Name

Contact Information

Pertaining to the payment card
Race day info will be sent to email address provided

Country*
State / Province*
Address*
City*
*
*
*
*
*
*
Email*
Confirm Email*
Phone*

Payment Information

Amount*
$
Name on Card*
Card Number*
Additional Comments

Security Code

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