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Visit The Joseph Brant Memorial Hospital Website

ONLINE REGISTRATION

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Already filled out the form and need to complete your team member registration?

Click here to complete your registration!

Team Type:

I'm Registering a:

Participant #1

You must register at least one participant at this time. If you would like to register additional Participants, click on the green plus signs below.

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:

Race Info

Build your Own Bed Or Rent?: Build our Own
Will Need A Rental ($100 Rental Fee Required) Team Name:

Which one of the above participants is your team captain? If none of the above, please provide name and contact details of team captain.

Team Captain:

Info: Please provide a brief description in the space below of your team that may be used by the race announcer, in race materials and media coverage

Description:

Challenge:

We wish to challenge the below mentioned to participate in the Amazing Bed Race.

Group Name: Contact Name: Telephone #: Email Address:

Payment:

Current Balance: $0

VISA
MasterCard Card Number: Expiry (MM-YY): Name as Shown on Card: CSC Number (3-4 Digits on Back of Card):

Payment information will be sent via SSL 256 bit Encryption.

REGISTRATION FORMS

Registration Form

Amazing Bed Race Waiver

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

All teams must pre-register.

Note: No Refunds on Registration After September 13th
Limited Rental Beds Available
Registration Deadline September 1, 2011
Drop Out Date Without Penalty - Thursday September 1, 2011
No Refunds for Team's Who Withdraw After - Thursday September 1
Entry fees are waived if a team raises more than $1550 in paid pledges.
If a Team raises more than $2000 in paid pledges a 6ft HEAD START PASS will be awarded to be used at the Team's discretion during the qualifying rounds only.
Bed Rental Fee of $100 if required

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