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 Events Manager Morgan Memorial Goodwill Industries 1010 Harrison Ave. Boston, MA 02119 Email: eflaherty@goodwillmass.org Phone: 617-541-1255 Fax: 617-541-1493 Personal Information: Last Name First Name Home Address City State Zip Date of Birth Preferred Email Address Preferred Phone Number Employer Job Title Work Address City State Zip Alternative Phone Number Application Type: I am applying for a bib to run and fundraise on behalf of Morgan Memorial Goodwill Industries as a member of Running for Great Kids I have already secured an official entry from the B.A.A. and would like to run and fundraise on behalf of Morgan Memorial Goodwill Industries Running for Great Kids
2 My Motivation: I heard about Running for Great Kids from: I would like to run for Running for Great Kids because (include additional pages, if needed): Fundraising: My minimum fundraising commitment (minimum required is $5,000): $ My fundraising goal: $ Does your company plan to support your fundraising efforts? (check all that apply) Yes, my company will support me through a donation. Yes, my company will match any gifts made by me or my colleagues. No, my company will not support my efforts. Have you participated in a marathon/road race charity program before? Yes No If yes, for which charity and how much money did you raise? Charity Name Amount raised: $ Please outline your plan for meeting your fundraising goal (include additional pages, if needed)
3 My Running Experience: My running level: Beginner Intermediate Advanced Current Weekly Mileage: Typical training pace (min/mile): Number of Boston Marathons I have run: Number of previous marathons (anywhere) I have run: Will you attempt to participate in our optional team runs/workouts? Yes No Additional Information: Social networking sites I actively use: Facebook LinkedIn Instagram Vine Twitter (@ ) I have a blog: Yes No Hometown newspaper (please specify town and state): You have my authorization to use this information for media, promotion, etc. Yes No My other hobbies/sports/interests/community & volunteer activities: Goodwill will host a few team meetings before the Marathon. Will you be able to attend these meetings? Yes No If no, what is the reason? If you reside out of state, do you have family, social, or business ties in or around Boston, or within Massachusetts?
4 Morgan Memorial Goodwill Industries Terms and Conditions for the 2017 Boston Marathon Team Please read the following carefully before signing below. Fundraising Commitment: The minimum commitment required to join Goodwill s Marathon Team and receive an individual entry for the 2017 Boston Marathon is $5,000. A non-refundable deposit of $100 will be charged to your credit card when you are accepted onto the team. The $100 will be applied toward your fundraising minimum and reserves a Boston Marathon number in your name. The remaining balance is due by Friday, April 28, 2017, and can be comprised of donations or personal funds. Valid credit card information must be included with your application to apply for Goodwill s team. The card must not expire before July 1, 2017. In the event that you do not meet the minimum donation requirement on April 28, 2017, Goodwill reserves the right to charge the balance owed to your credit card without notice. MasterCard, Visa and American Express are accepted. Cancellation Policy: You may cancel your selection to Goodwill s team for the Boston Marathon due to injury, illness or extenuating circumstances, waiving your responsibility for the $5,000 minimum anytime on or before January 6, 2017. To do so, you must contact Erin Flaherty Barfield, Events Manager at Goodwill, in writing, on or before the cancellation date. Your $100 deposit fee is non-refundable and you must forfeit the marathon bib number if you cancel your participation by January 6, 2017. After January 6, 2017, you are responsible for raising the $5,000 minimum, even if for any reason, including injury, you are unable to run in the Marathon. Your marathon waiver is non-transferable if you cancel after January 6, 2017. Donations raised and received by Goodwill cannot be refunded, even if you cancel before January 6, 2017. Matching Gift Policy: Many companies match employees charitable contributions. You can check with your employer to see if your company has this program, and ask donors if their employers match gifts. Many companies issue matching gift checks quarterly or semi-annually: therefore if you plan to use a match to reach your minimum, it is your responsibility to contact the matching company to ensure the check will be issued before April 28, 2017. If the company s match cycle is past April 28, 2017, the match cannot count towards your minimum. Team Member s B.A.A. Registration: Goodwill will inform you of the details of the B.A.A. registration process after your application is accepted. The B.A.A. charges a race application fee of $355 that does not count towards your fundraising commitment. Registering with the B.A.A. and paying the registration fee are your responsibility and must be completed within the deadlines set forth by the B.A.A.. You should NOT contact the B.A.A. directly to secure your number. Release Form and Contribution Agreement: In consideration of my accepting this entry, I hereby for myself, my heirs, executors and administrators, waive and release any and all rights for claims and damages I may have against Morgan Memorial Goodwill Industries, its employees, volunteers, officers and sponsors for any and all injuries suffered or sustained by me in said event, in the training and planning sessions for said event, or travel to or from any of the preceding. I further attest and certify that I am 18 years or older, physically fit and have sufficiently trained for participation in this event, and a licensed medical doctor has verified my physical condition. I also grant permission for use of my name and or photograph or voice in broadcast, telecast, print or any other account of this event and agree to waive any
compensation for such use. I agree to collect a minimum of $5,000 for Goodwill by April 28, 2017. If I have not raised the minimum in donations by that date, I will personally be responsible for the balance owed. I understand that unless I cancel by January 6, 2017 Goodwill reserves the right to charge the balance I owe to my credit card after April 28, 2017. I declare that I have exercised my own judgment in signing this agreement and I further declare that the decision to sign this agreement was voluntary and not based on or influenced by any representative of Goodwill. I agree and understand that I am solely responsible for raising the minimum $5,000 and will be faithful to my commitment to Goodwill. Signature: Date: 5 Emergency Contact Information: In the event of an illness, injury or medical emergency arising during the event or in the training and planning sessions for said event, I hereby authorize and give my consent to Goodwill to secure from any accredited hospital, clinic and/or physician any treatment deemed necessary for my immediate care. I agree that I will be fully responsible for payment of any and all medical services and treatment rendered to me including but not limited to medical transport, medications, treatment, and hospitalization. The following person should be contact in the event of an emergency: Name: Relationship to Runner: Telephone Number: Allergies to medications: Please complete credit card information on the following page.
6 Credit Card Information: MasterCard Visa American Express Name on Card: Address (if different from address on page 1): Card Number: Expiration Date: Signature of Card Holder: Date: