THE GREAT RADIOTHON RACE

Registration Form October 19, 2013 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 6, 2013

Make cheques payable to: Wingham and District Hospital Foundation Mail to: 270 Carling Terrace, PO Box 1228, Wingham, ON, N0G 2W0 OR 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): 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 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

The team that raises the MOST pledges will get to select one other team to be delayed 1 minute at the start of the race. Use this power wisely! Each participant who collects $100 - $200 will receive a $10 gift certificate to a local business Each participant who collects $200 - $500 will receive a $20 gift certificate to a local business Each participant who collects more than $500 will receive a $50 gift certificate to a local business Prizes are generously sponsored by HOWICK MUTUAL INSURANCE COMPANY

***GRAND PRIZE***
The team who reaches the finish line first will win

$300! BRING ALL YOUR PLEDGES WITH YOU ON RACE DAY.

THOSE USING PAPER METHOD: BRING ALL YOUR PLEDGES ON RACE DAY WITH THE PLEDGE FORM. THOSE USING ONLINE METHOD: BRING A PRINT-OUT OF YOUR TOTAL DONATIONS. Online Method 1. Go to www.canadahelps.org 2. Click on GivingPages under Ways to Give 3. Click Create a GivingPage under Your Giving Page 4. Create a new account under Use Your CanadaHelps Account or sign up using your Facebook Account under Use one of these: 5. When asked Which account type would you like to register for? select GivingPage Account 6. Fill in your personal information 7. Add Wingham and District Hospital Foundation as your charity 8. Fill in event and team name information. (Event Type: Sporting Event.) 9. Add a picture! We suggest one of you and your team mate 10. Make sure you share your fundraising goal with you supporters 11. Share your page with your friends and family on Facebook, Twitter, via email, etc. Direct anyone who would like to support you to your GivingPage. 12. Bring a print-out of your total donated pledges with you when you check-in on race day.

If you have any trouble setting up your account contact Nicole Duquette at the Foundation office. 519-357-3711 x 5278 or at wdh.foundatoin@lwha.ca or you can contact the CanadaHelps info line at 1-877-755-1595.

Paper Method If you prefer to raise pledges the traditional way or to combine the paper method and the online method, print the following page, record and collect your pledges. Bring your form AND all your collected funds on race-day (no to-be-paid please). If you choose to combine the paper and the online methods please be sure to include your online total on your paper pledge form.

THE GREAT RADIOTHON RACE

Pledge Form (use as many sheets as you need) BRING PLEDGE FORM AND PLEDGES ON RACE DAY. YOUR TOTAL TEAM AMOUNT SHOULD MATCH YOUR TEAMMATES 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 $____________________ MYTOTAL AMOUNT $ __________ TEAMSTOTAL AMOUNT $ _________
Page _______ of _______