The VIRTUAL Great Hospital Race Registration

Registration by Free-will Donation

You will receive a tax-deductible receipt for the amount of your donation

Donation Amount*
  • $250
  • $100 - eligible for 2 t-shirts
  • $50 - eligible for 1 t-shirt
  • $25
  • Other $

Contact Info Related to Payment Method

Country*
Email*
Confirm Email*
Phone*
Team Name*
Full Names - All Team Members over age 18*
Disclaimer*

Yes, all of the above named individuals, hereby declare they will not hold the Wingham & District Hospital and/or Wingham & District Hospital Foundation responsibly liable for any loss, damage, injury, infection or Death that may occur while participating in the event.  Each named individual accepts this risk as their own total Responsibility and each named individual fully understands the implication as stated above and in accepting assume the same for dependent children.

Full Names - All Team Members under 18
Parent/Guardian Disclaimer

Yes, as the parent(s) and/or Legal guardian(s) of the above named minors hereby give permission for the above named to participate in the Great Hospital Race on the basis of the conditions set.

Payment Information

Amount*
$
Payment Type
We only accept credit/debit card payments. After you complete this form, select Submit to enter your card details into our secure transaction processor. Your submission will be processed when you finalize your secure payment information.
Additional Comments

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