1 Morgan Memorial Goodwill Industries Running for Great Kids 2016 Falmouth Road Race 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 Falmouth Road Race 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: Fundraising: My minimum fundraising commitment (minimum required is $1,000): $ 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 road race charity program before? Yes No If yes, for which charity and how much money did you raise? Charity Name Amount raised: $ I plan to raise funds for Running for Great Kids through the following methods: Who do you plan to solicit for donations?
3 My Running Experience: My running level: Beginner Intermediate Advanced Current Weekly Mileage: Typical training pace (min/mile): Number of Falmouth Road Races I have run: 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 at least one team meeting before the Falmouth Road Race. 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 2016 Falmouth Road Race Team Please read the following carefully before signing below. Fundraising Commitment: A minimum donation of $1,000 is required to join Goodwill s Falmouth Road Race Team and receive an individual entry for the 2016 Falmouth Road Race on Sunday, August 21, 2016. 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 Falmouth Road Race number in your name. The remaining balance is due by Friday, September 2, 2016. Valid credit card information must be included with your application to apply for Goodwill s team. The card must not expire before December 31, 2016. In the event that you do not meet the minimum donation requirement on September 2, 2016, 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 participation with Goodwill s team for the Falmouth Road Race, waiving your responsibility for the $1,000 minimum anytime on or before August 7, 2016. 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 entry if you cancel your participation by August 7, 2016. After August 7, 2016, you are responsible for raising the $1,000 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 August 7, 2016. Donations raised and received by Goodwill cannot be refunded, even if you cancel before August 7, 2016. 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 September 2, 2016. If the company s match cycle is past September 2, 2016, the match cannot count towards your minimum. Team Member s Falmouth Road Race Registration: Goodwill will inform you of the details of Falmouth Road Race registration after your application is accepted. Registering with the race organizers is your responsibility and must be completed within the deadlines set forth by the Falmouth Road Race. You should NOT contact the Falmouth Road Race 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 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 agree to collect a minimum of $1,000 for Goodwill by September 2, 2016. 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 August 7, 2016 Goodwill reserves the right to charge the balance I owe to my credit card after September 2, 2016. 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 $1,000 and will be faithful to my commitment to Goodwill. Signature: Date: 5 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: 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: