2016 TCS New York City Marathon Wediko Team Application

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1 2016 TCS New York City Marathon Wediko Team Application Running the TCS NYC Marathon there s nothing quite like it. The five boroughs, the cheering crowd, finishing in Central Park. Glad you are considering not only running NY, but running for Wediko Children s Services! Thank you for taking the time to complete this application. Wediko believes children s mental health matters and that children do best when all of the adults in their life are working together. On behalf of the children, families, and schools served by Wediko, we thank you for considering making a difference in these young lives by joining our team and fundraising for Wediko. To be considered for selection to the 2016 Wediko TCS New York City Marathon team, you must complete an application. Please send your complete application as soon as possible. Team selection will happen on a rolling basis. We are looking forward to a successful and exciting marathon training season! Send completed applications to to: Kate Patton Regal Wediko Children s Services E. Dedham St. Boston, MA Fax: Phone: kregal@wediko.org (you can also a scanned copy)

2 Benefits of being a member of the Wediko Marathon Team: Guaranteed race entry for the 2016 TCS New York City Marathon on November 6, 2016 Connect with a team of runners who are committed to training for a marathon and raising money to support Wediko Receive weekly coaching and fundraising support from the Wediko coach who has run Boston 13 times and raised over $160,000 for charity Fundraising handbook with strategies to assist you in raising money Online fundraising page Wediko Marathon Team running singlet, training shirt, and post-race gathering The knowledge that the miles you train and the race you run makes a difference for children and families struggling with social, emotional, and academic challenges. Responsibilities of being a member of the Wediko Marathon Team: Set a fundraising goal of at least $4,000 (minimum commitment = $2500) Be physically able to complete the marathon in under 6 hours. Pay race entry fee ($255) to NYRR Wear Wediko team singlet in 2016 TCS New York City Marathon

3 2016 TCS New York City Marathon Wediko Team Application (If you have secured your own TCS New York City Marathon entry and are interested in joining the Wediko Marathon team, we would love to have you! Please Last Name First Name MI Street Address City State Zip Address Home Phone Cell Phone Work Phone I prefer to be contacted at Home Work Cell Employer Title Work Address Does your company have a Matching Gift program? Yes No Gender : M F DOB: / / T-shirt Size: Singlet Size: We would like to know more about you. (Add another page if necessary) Please tell us about: Your Running Experience: Have you run a marathon before (circle one): Yes No How many? Time in most recent marathon: Have you run a half-marathon before (circle one): Yes No How many? Time in most recent half-marathon: Please describe your interest in running and your average pace:

4 Your Fundraising Experience: Have you ever raised significant funds for a program/charity before? Yes No How much did you raise? If yes, for which charity and how much money did you raise? Charity Name Amount raised: $ Charity Name Amount raised: $ Other: Have you participated in a marathon/road race charity program before? Yes No If yes, what was the event? What is your fundraising goal for the Wediko TCS New York City Marathon team? $ How do you plan to raise these funds? (Please be as detailed as you can about your plans). Please tell us about your interest in joining the Wediko Marathon Team:

5 Wediko Children s Services Terms and Conditions Please read the following carefully before signing below. Application Process: We will notify you that we have received your completed application within seven days of receipt. At that time we will schedule a time to talk by phone. Selection to the team is made on a rolling basis. There is no set deadline, however, please submit your application as soon as possible. Cancellation Policy: You may cancel your participation with the Wediko Marathon Team for the TCS New York City Marathon, waiving your fundraising responsibility anytime on or before July 31, To do so, you must contact Kate Regal in writing on or before this date. Any donations received by our office are non-refundable, regardless of when received or your status on the team. After July 31, 2016, you are responsible for raising the fundraising minimum, even if for any reason, including injury, you are unable to run the Marathon. Fundraising Commitment: Fundraising Milestone Due Date $100 July 14, 2015 $2,000 September 14, 2015 $4,000 October 12, 2015 We ask for a minimum donation or fundraising commitment of $4,000 to join the Wediko Marathon Team and receive guaranteed entry for the 2016 TCS New York City Marathon. We require a nonrefundable deposit of $100 once you accept a position on the Wediko team. This fee will be applied toward your fundraising minimum and holds a TCS New York City Marathon number in your name until July 31, After July 31, 2016, you will be required to raise $4,000 and will have until November 1, 2016 to do so. Valid credit card information (with an expiration date later than December 2016) must be included with your application to apply for the Wediko Marathon Team. In the event that you do not meet the minimum donation requirement by the established deadlines (July 14, 2016, September 14, 2016 and November 1, 2016) Wediko reserves the right to charge the balance owed to your credit card, unless prior arrangements have been made. We will reimburse your card upon written request once you meet the minimum. After December 1, 2016, we will no longer reimburse your card.

6 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 November 1, Please note: Matching gifts not received by our office by the November 1 deadline cannot count towards your minimum. NYRR Race Entry: Wediko will inform you of the details of the NYRR race entry procedures after your application is accepted. The NYRR charges a race entry fee of $216 for NYRR members and $255 for non-members that is paid directly to the NYRR and does not count towards your fundraising. The fee is collected separately, at a later date. You should not contact the NYRR directly to secure your number. Official Entrants: Wediko welcomes registered runners and other official entrants to join the 2016 Wediko Marathon Team and run to raise money towards our mission. Qualified entrants and those who receive race entry from another source are asked to raise a minimum of $750 to participate and take advantage of team events and benefits. Qualified runners are responsible for their own race registration. We will provide you with a personalized fundraising page. Wait list: Wediko Children s Services has the opportunity for five official runners to participate in the 2016 TCS New York City Marathon as part of our charity team. Wediko will maintain a waitlist of runners. Waitlisted runners should be prepared to step in should any member of the team drop out. If a waitlisted runner is called upon to join the team and run the Boston Marathon, he/she will be responsible for raising the minimum due ($4,000) by November 1, As a courtesy, please notify Kate Regal if you are no longer interested in running for Wediko.

7 Release Form and Contribution Agreement: In consideration of my joining the Wediko marathon team, I hereby for myself, my heirs, executors and administrators, waive and release any and all rights for claims and damages I may have against Wediko Children s Services, 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 proceeding. I further attest and certify that I am physically fit and have sufficiently trained for competition 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 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 $4,000 for Wediko Children s Services by November 1, If I have not reached the minimum in sponsorships by that date, I will personally be responsible for the balance owed. I understand that unless I cancel by July 31, 2016, Wediko Children s Services reserves the right to charge the balance I owe to my credit card on the July 14, 2016, September 14, 2016 and November 1, 2016 fundraising deadlines. 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 representation of Wediko Children s Services. 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 Wediko Children s Services 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 medical services and treatment rendered to me including but not limited to medical transport, medications, treatment, and hospitalization. I hereby accept and agree to the terms and conditions set forth in these Terms and Conditions Signature: Date: Print Name:

8 Please provide your Credit Card Information (held on file but not stored. It will be destroyed when the fundraising commitment is achieved.) Type of Credit Card: MasterCard Visa American Express Name on card: Card Number: Exp. Date: Security Code: address of card holder: Signature of card holder: Billing address (if different than home address listed previously): Emergency Contact Information: The following person should be contacted in an emergency: Name: Relationship: Telephone Number(s): H: C: W: : Applicant Medical Information: Allergies to Medications: Other relevant medical information: Thanks again for your interest in running for Wediko and raising much needed funding! We appreciate the time you took to fill out our application. You will hear from us as soon as we receive your application. In the meantime, please notify us of any changes to your application, including a change in interest. Good Luck!

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