APPLICATION. Team Clarke 2017 TCS New York City Marathon Sunday, November 5, 2017

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Vanessa Randall
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1 APPLICATION Team Clarke 2017 TCS New York City Marathon Sunday, November 5, 2017 Clarke School for the Deaf (dba Clarke Schools for Hearing and Speech) provides children who are deaf or hard of hearing with the listening, learning and spoken language skills they need to succeed. Annually, more than 1,200 children and their families benefit from programs and services at our locations in Boston, Jacksonville, New York, Northampton and Philadelphia. Clarke impacts the lives of children and adults through educational and early childhood programs, hearing services, mainstream services, research, curriculum development and through the teachers and professionals trained by Clarke who take their special skills to all parts of the world. Volunteer-fundraisers are incredibly important to us as they not only help to increase the financial wherewithal of the organization but they also introduce new friends to Clarke, spreading awareness of the incredible outcomes now possible for children with hearing loss. Thank you for your interest in being part of the Clarke community! Completed, signed applications can be returned by , fax, or mail to: Christina Danese, Development Associate Clarke Schools for Hearing and Speech 80 East End Avenue New York, NY T: F: Please note: we will be reviewing applications as they are received and will respond to you with the status of your application within three (3) business days. Clarke Schools for Hearing and Speech Team Clarke Runner Agreement/Waiver Page 1

2 Application Form (Please print clearly) First Name Last Name Date of Birth (MM/DD/YY) Gender (Male or Female) Address Home Phone Cell Phone Employer Title Work Address Work Phone Fax Preferred Address I would like to receive mail at: Home Work Participation Type! A. Guaranteed Entry: I would like to secure a guaranteed race entry on Team Clarke. The minimum fundraising requirement for a guaranteed race entry is U.S. $2,500 (two thousand five hundred dollars). Please indicated your personal goal: $.! B. Runners Who Have Already Received Entry: I already have a guaranteed race entry for the 2017 TCS New York City Marathon and would like to become a member of Team Clarke. Please indicate your fundraising goal: $. We suggest a minimum fundraising goal of U.S. $500 (five hundred dollars). I give my permission to Clarke Schools for Hearing and Speech to include my contact information in a team roster which will be distributed among the team. Yes No Clarke Schools for Hearing and Speech Team Clarke Runner Agreement/Waiver Page 2

3 A. FUNDRAISING AGREEMENT FOR GUARANTEED ENTRY As a runner on Team Clarke, you agree to raise a minimum (or make a personal contribution) of U.S. $2,500 on behalf of our organization by December 31, We ask for credit card information to secure your space on our team and to ensure that the minimum is honored. Upon acceptance to the team, we will provide you with details of registration in the 2017 TCS New York City Marathon. You should NOT contact New York Road Runners (NYRR) directly to secure your race number. NOTE: NYRR charges a race entry fee which is separate from and does not count towards the $2,500 fundraising minimum. This fee will be collected directly by NYRR ( after acceptance to Team Clarke is confirmed. As your biggest supporter, Clarke Schools for Hearing and Speech will provide you with information to boost your fundraising efforts and which will make it easy for you to solicit and collect donations and monitor your progress toward your fundraising goal. Charity begins at home, as the saying goes. We hope you ll kick off your fundraising efforts by making your own gift to Clarke. It will help to change the lives of the young children and families we serve. Matching Gift Policy Many companies match employees charitable contributions. Matching gifts will be counted toward your fundraising goal. Clarke Schools for Hearing and Speech encourages you to check with your employer to see if your company has a matching gift program, and to ask your donors if their employers match gifts. It is your responsibility to contact the matching company to ensure the matching gift form will be issued before December 31, If Clarke does not receive the matching gift form prior to that date, the match cannot count towards your fundraising minimum. Cancellation Policy You are responsible for raising the $2,500 minimum even if for any reason, including injury, you are unable to run in the marathon. Release Form and Contribution Agreement In consideration of accepting this entry, I and on behalf of myself, my heirs, executors and administrators, and my estate hereby waive and release any and all rights and claims against Clarke Schools for Hearing and Speech and its sponsors, including but not limited to any and all damages, and any and all injuries suffered by me in said event. I further attest and certify that I am of good health and am physically fit to compete in the 2017 TCS New York City Marathon, and a licensed medical doctor has verified my physical condition. I also grant permission to Clarke Schools for Hearing and Speech for its use of my name, my likeness, my image, statements made by me and/or voice in broadcast, telecast, print or any other format for this event. I agree to collect and/or make a personal contribution of the fundraising minimum of U.S. $2,500 for Team Clarke by December 31, If I have not reached the minimum in sponsorship by that date, I will be personally responsible for the balance owed. I understand that Clarke Schools for Hearing and Speech reserves the right to bill the balance I owe to my credit card on December 31, Clarke Schools for Hearing and Speech will contact me before any additional charges are made to my credit card. By signing this completed application, you are agreeing to the terms of becoming a member of Team Clarke and the fundraising commitment. Participant Signature Date Clarke Schools for Hearing and Speech Team Clarke Runner Agreement/Waiver Page 3

4 Credit Card Information Credit Card Type (Circle One): American Express Visa MasterCard Discover Name (as it appears on your credit card) Credit Card Number Expiration Date Security Code Billing Address I would like to start fundraising with my own gift to Clarke!! Please charge $ to my credit card.! I am sending a check in the amount of $, payable to Clarke Schools for Hearing and Speech, to Clarke Schools for Hearing and Speech, 45 Round Hill Road, Northampton, MA ! I am making my gift of $ online at Shirt Size (Circle One): Male: Small Medium Large X Large XX Large Female: X Small Small Medium Large X Large Clarke Schools for Hearing and Speech Team Clarke Runner Agreement/Waiver Page 4

5 B. FUNDRAISING AGREEMENT FOR RUNNERS WHO HAVE ALREADY RECEIVED ENTRY A non-refundable U.S. $50 (fifty dollar) minimum donation is required to secure a spot on Team Clarke. A valid credit card must be provided upon acceptance for Clarke Schools and Hearing and Speech s 2017 TCS New York City Marathon team. We suggest a minimum fundraising goal of $500 (five hundred dollars). Matching Gift Policy Many companies match employees charitable contributions. Matching gifts will be counted towards your fundraising goal. Clarke Schools for Hearing and Speech encourages you to check with your employer to see if your company has a matching gift program, and to ask your donors if their employers match gifts. It is your responsibility to contact the matching company to ensure the matching gift form will be issued before December 31, If Clarke does not receive the matching gift form prior to that date, the match cannot count towards your fundraising minimum. Cancellation Policy You are responsible for collecting the agreed to fundraising minimum even if for any reason, including injury, you are unable to run in the marathon. Release Form and Contribution Agreement In consideration of accepting this entry, I and on behalf of myself, my heirs, executors and administrators, and my estate hereby waive and release any and all rights and claims against Clarke Schools for Hearing and Speech and its sponsors, including but not limited to any and all damages, and any and all injuries suffered by me in said event. I further attest and certify that I am of good health and am physically fit to compete in the 2017 TCS New York City Marathon, and a licensed medical doctor has verified my physical condition. I also grant permission to Clarke Schools for Hearing and Speech for its use of my name, my likeness, my image, statements made by me and/or voice in broadcast, telecast, print or any other format for this event. I agree to collect and/or make a personal contribution of the fundraising minimum of U.S. $ for Team Clarke by December 31, By signing this completed application, you are agreeing to the terms of becoming a member of Team Clarke and the fundraising commitment. Participant Signature ` Date Clarke Schools for Hearing and Speech Team Clarke Runner Agreement/Waiver Page 5

6 Credit Card Information Credit Card Type (Circle One): American Express Visa MasterCard Discover Name (as it appears on your credit card) Credit Card Number Expiration Date Security Code Billing Address (if different than above):! Please charge my non-refundable donation of $ (minimum of U.S. $50) to this credit card.! I am sending a check in the amount of $, payable to Clarke Schools for Hearing and Speech, to Clarke Schools for Hearing and Speech, 45 Round Hill Road, Northampton, MA ! I am making my gift of $ online at Shirt Size (Circle One): Male: Small Medium Large X Large XX Large Female: X Small Small Medium Large X Large Clarke Schools for Hearing and Speech Team Clarke Runner Agreement/Waiver Page 6

Morgan Memorial Goodwill Industries Running for Great Kids 2017 Boston Marathon Team Application

1 Morgan Memorial Goodwill Industries Running for Great Kids 2017 Boston Marathon Team Application Applications will be accepted on a rolling basis. Send completed applications to: Erin Flaherty Barfield