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Visit the Rotary Club of Burlington Web Site

Visit The Joseph Brant Memorial Hospital Website

REGISTRATION FORMS

Amazing Bed Race Waiver

* Must be signed and submitted by each team member in order to participate.

COMPLETE ONLINE REGISTRATION

Please complete the form below to complete your registration. All fields are mandatory. If you have not yet paid please complete the full registration form by clicking on the "Registration Form" button above.

Team Name:

Participant #1

Firstname: Lastname: Address: Telephone #: Email Address: Date Of Birth (Month - Day - Year): Age on Race Day:

Participant #2

Firstname: Lastname: Address: Telephone #: Email Address: Date Of Birth (Month - Day - Year): Age on Race Day:

Participant #3

Firstname: Lastname: Address: Telephone #: Email Address: Date Of Birth (Month - Day - Year): Age on Race Day:

Participant #4

Firstname: Lastname: Address: Telephone #: Email Address: Date Of Birth (Month - Day - Year): Age on Race Day:

Participant #5

Firstname: Lastname: Address: Telephone #: Email Address: Date Of Birth (Month - Day - Year): Age on Race Day:

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