29th Annual waiver form Participant Signature Parent/Guardian Signature, if participant(s) under 18 Motorcycle miracle tour Contributions to Children’s Miracle Network at Geisinger Health System provide pediatric equipment, programs and services for Geisinger Janet Weis Children’s Hospital in Danville, Geisinger Wyoming Valley Medical Center in Wilkes-Barre, Geisinger Shamokin Area Community Hospital, Geisinger Community Medical Center in Scranton, Geisinger Bloomsburg Hospital and more than 40 medical groups and pediatric specialty outreach clinics throughout the state. NCE 1986 SI NG GKB TO UR O DA Y helping to make miracles happen benefiting Geisinger Janet Weis Children’s Hospital pediatric services TO MO IVI G In consideration of permission for the undersigned Participant(s) to participate in the Motorcycle Miracle Tour, Participant(s), intending to be legally bound hereby, hereby agree for Participant(s) and for Participant(s) heirs, executors, administrators and assigns, that Participant(s) will and hereby release and forever discharge Motorcycle Miracle Tour, Geisinger Health System Foundation, its affiliated corporations, and all other persons, associations and corporations, both known and unknown, and their respective agents, servants, employees, board of directors, members, heirs, executors, administrators, assigns and insurers (hereinafter called "Grantors") from all manner of claims, actions or causes of action which Participant(s) now have or which Participant(s) or Participant(s) heirs, executors, administrators, assigns hereafter can, shall or may have because of bodily injury, including death, or damage or loss to property which Participant(s) may suffer while participating in the above activity, whether the said injury, including death, or damages may be due to a negligent act or omission of the said Grantors, or otherwise. It is acknowledged that the risks of injury or damages may be inherent in this activity and that Participant(s) accept full responsibility for Participant(s) own voluntary decision to participate in the activity and Participant(s) fully assume the risks of injury and damages from both known and unknown causes, both obvious and hidden conditions and conditions for which warnings were or were not specifically provided. It is additionally understood that Participant(s), who may in any fashion be employed by Geisinger Health System Foundation, Geisinger Clinic, Geisinger Medical Center, Geisinger Wyoming Valley Medical Center or any one of the affiliated Geisinger Corporations not herein noted specifically, is (are) voluntarily entering into the aforementioned activities outside of the course and scope of their employment and will not under any circumstances, should injury occur during these activities, qualify or be entitled to Workmen's Compensation or any other specific Compensation or benefit that may be applicable to injuries that may occur during the course and scope of employment, for any injuries suffered from their participation in the above noted activities. RC LE YC T LE MIRAC E CH UR ILD R E N TH E F U T All Children’s Miracle Network donations in our region stay local, benefiting children in central and northeastern Pennsylvania. For more information, call 1-800-322-5437 or (570) 271-6188, or visit geisinger. org/cmn. Children’s Miracle Network at Geisinger Geisinger Health System Foundation 100 N. Academy Ave., MC 50-20 Danville, PA 17822-5020 Phone: 570-271-6188; 1-800-322-5437 Fax: 570-214-9776 geisinger.org/cmn The official registration and financial information of GHSF may be obtained from the Pennsylvania Department of State by calling toll-free, within Pennsylvania 1-800-732-0999. Registration does not imply endorsement. A person may obtain from the New York State Attorney General’s Charities Bureau, Attn: FOIL Officer, 120 Broadway, New York, NY 10271, a copy of the last annual report filed by GHSF with the attorney general. GHSF will also provide, upon request, a description of the programs and activities for which it has requested contributions. GHSF may from time to time make contributions to other charitable organizations and, upon request, will provide a list of all such organizations which have received contributions from GHSF during the past twelve months. Sunday, June 1, 2014 “Giving children the future today!” REGISTRATION Register by mailing registration form and $17 payment before May 10. Pre-registration includes a T-shirt. Riders must present t-shirt coupons at Knoebels. Please enclose a self-addressed stamped envelope and your payment (checks or money orders may be made payable to “Geisinger Health System Foundation”). Mail all materials before MAY 10 to: Children’s Miracle Network at Geisinger Attn: Motorcycle Miracle Tour, 100 N. Academy Ave., M.C. 50-20, Danville, PA, 17822. Register online at events.geisinger.org. DAY-OF REGISTRATON: Register at Geisinger Medical Center campus Sunday, June 1between 8 a.m. and Noon. $20 registration includes a bandanna. pLEDGE INFORMATION & CLUB DONATIONS Riders collect pledges to benefit Children’s Miracle Network at Geisinger. Awards given to to riders raising pledges at the $50 - $200 level; the $201 - $600 level; and the $601 and up level. If your club is planning a fundraiser for the Motorcycle Miracle Tour, call the Children’s Miracle Network office at (570) 271-6188 for supplies.. Turn in your donation at the MMT tent at Geisinger Medical center by noon June 1. Awards will be given to the top fundraiser; plaques will be given to clubs raising more than $100. Please download pledge and donation materials at www. geisinger.org/cmn. AWARDS & TOUR PRIZES Awards will be given to the oldest male & female drivers; the male & female drivers who traveled the farthest; the oldest veteran rider; the largest participating club; the top 3 individual fundraisers; and the top fundraising club. Trophies will be awarded at 2 p.m. at Knoebel’s Amusement Resort, Elysburg. Tour prizes will be held until after all trophies have been awarded. PLEASE NOTE: All riders must sign the American Motorcycle Association’s (AMA) waiver and deposit the ticket stub to be eligible for tour prizes. REGISTRATION form Name(s) SANCTIONED 29th annual motorcycle miracle tour when: Sunday, June 1, 2014 Bikes depart between 9 a.m. and noon where: Departs from: Geisinger Medical Center 100 N. Academy Drive Danville, Pennsylvania Register for the 29th-annual Motorcycle Miracle Tour to support Geisinger Janet Weis Children’s Hospital pediatric services through Children’s Miracle Network at Geisinger. The ride is part of Celebration Weekend activities and begins at Geisinger Medical Center in Danville, Pa. (I-80 Exit 224; follow hospital signs), with bikes leaving between 9 a.m. and noon. Final destination is Knoebels Amusement Resort, Elysburg. Street address City, State, ZIP Phone E-mail Club name AMA member? Qty Yes No Registration Cost: $17 per person Persons $ (includes MMT t-shirt) Qty Breakfast All-you-can-eat breakfast buffet Cost: $6 per person $ (Price for pre-registered riders only) Qty Lunch Cost: $8 per person Lunch at Knoebel’s $ Total amount enclosed $ SHIRT SIZES: S M L XL XXL Quantities: Questions For more information on the Motorcycle Miracle Tour, call Bernie Bredbenner Jr. at (570) 745-3835 or the Children’s Miracle Network office at (570) 271-6188 or 1-800-3225437, or visit geisinger.org/cmn.
© Copyright 2024 ExpyDoc
