Kidney Day at Kennywood Individual Registration Form
Please complete this form and return it to your unit’s Coaster Representative. Please keep the receipt
portion for your records.
Dialysis & transplant patients & staff may purchase:
FunDay Passes for $21.00 each. Catered picnic-style dinners (includes fountain drinks) are $16 each.
Please check one: Dialysis Patient Transplant Patient Dialysis Staff Transplant Staff
City________________________________________________________ State _______ Zip___________
# Tickets at $21.00 each:___________ # Catered picnic-styled dinner at $16.00 each:_______________
Total number of meals needed for the May 29th catered picnic-style dinner ______ (do not include meals
for children under 5 in your total).
Please print first and last names below of people that will receive a catered picnic-style dinner on May 29th.
Kennywood Park requires us to identify the ages of FunDay Ride Pass holders.
Please identify the number of people in both age brackets.
Under age 5 _____ Ages 6 to 17 _____ Adult 18 to 54 _____ Senior 55+_____
Kidney Day at Kennywood Receipt
This portion of the form is for the patient or staff member once payment has been made.
_____# of $21.00 Tickets purchased; _____# of $16.00 Catered picnic-styled dinner purchased on May 29th
Amount paid $_____________ Payment Method Cash Money Order