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					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

Name_________________________________________________________________________________

Address________________________________________________________________________________

City________________________________________________________ State _______ Zip___________

Phone:_____________________________________E-mail:______________________________________

# 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.

Name ___________________________________

_____# of $21.00 Tickets purchased;    _____# of $16.00 Catered picnic-styled dinner purchased on May 29th

Amount paid $_____________                            Payment Method  Cash  Money Order

				
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