Ready, Willing & Able
2011 Philadelphia Marathon Fundraising Challenge
http://www.philadelphiamarathon.com/
November 19-20, 2011
WAIVER AND RELEASE
In submitting this entry, I hereby for myself and anyone entitled to act on my behalf, waive and release any and all rights to claim for damages I may have against Ready, Willing & Able, its parent non-profit, The Doe Fund, Inc., the 2011 Philadelphia Marathon, Half Marathon, the Rothman Institute 8K (“Maratjon Activities”), The City of Philadelphia, Fund for Philadelphia, The Active Network, USATF, all sponsors, and each of their employees, officers, directors, principals, agents, representatives, volunteers, contractors, successors, and assigns (the “Released Parties”), to any and all claims of damages, injuries, demands, actions, whatsoever, however they may occur, arising as a result of my participation in said Marathon Activities.
I acknowledge that I am aware of the inherent risks in participating in an athletic event of this type.
I further attest and verify that I am physically fit and have sufficiently trained for the completion of this event and my physical condition has been verified by a licensed medical doctor. I also acknowledge that I will present medically-certified proof of disability upon request to race organizers. Furthermore, I hereby grant full permission to any and all of the foregoing to use my name, my voice, and/or my picture in any broadcast, telecast, advertising, promotion or other account of this event for any purposes whatsoever. I grant the Philadelphia Marathon and its designated staff and medical providers access to my medical records and physicians, as well as any other information relating to medical care, my medical condition and medical treatment received as a result of my participation in this Philadelphia Marathon event.
CONTRIBUTION AGREEMENT AND READY, WILLING & ABLE FUNDRAISING PLEDGE:
I understand that:
● I agree to collect a minimum of $500 for Ready, Willing & Able by November 27, 2011, from donations provided by myself or obtained from other individuals or entities.
● I am required to provide a credit card by filling out the requested information below. This card will be charged a nonrefundable $100 deposit, an amount that will be applied toward my minimum fundraising pledge of $500.
● If I have not collected the minimum $500 by 11:59 pm Eastern Standard Time on November 27, 2011, I will be personally responsible for the balance owed. Ready, Willing & Able reserves the right to bill the balance of the pledge owed to the credit card I have provided on their website.
● My fundraising pledge reserves my placement in one of the race entry slots (i.e. Full Marathon , Half Marathon, and Rothman 8K) the Philadelphia Marathon has allotted to Ready, Willing & Able.
● Upon agreeing to participate to run for Ready, Willing & Able in the 2011 Philadelphia Marathon events, I will be provided a registration code and a welcome package by Ready, Willing & Able within 3 business days of registration.
● My registration number is nontransferable.
● I agree to abide by the “Special Rules of the Course” prescribed by the Philadelphia Marathon, and referenced on the Mail-in Registration Form (included in this Welcome Packet).
WITHDRAWALS:
● I have 72 hours from the time and date of registration to withdraw for any reason, by contacting Ready, Willing & Able through Michelle Smolka, Director of Development, by phone at 215-732-3781, by email at . Withdrawal within this period will relieve me of my fundraising pledge and no further charges will be applied. By withdrawing, I forfeit my guaranteed entry to the 2011 Philadelphia Marathon.
● If I withdraw from the 2011 Philadelphia Marathon at any time after 72 hours from when I registered due to personal reasons, injury, or for any reason at all, I must do so in writing to Ready, Willing & Able, c/ o Michelle Smolka by e-mail at or by letter at 1211 Bainbridge Street, Philadelphia, PA, 19147.
● Withdrawal in this manner will result in a charge of $150 applied to my credit card to cover Ready, Willing & Able’s fee for obtaining entries in the 2011 Philadelphia Marathon. Funds I have already raised will be credited towards the $150 fee.
● Should I fail to give written withdrawal notice to Ready, Willing & Able, I will be personally responsible for the full pledge amount and my credit card will be charged the remaining balance, if the full amount has not been contributed by the date of my withdrawal.
______
I understand and accept the above Waiver and Rules. I certify that the information provided above is true and accurate.
Check Event Type:
⎕ Rothman Institute 8K (Saturday, November 19th at 7:30 AM, 22nd Street and Ben Franklin Parkway)
⎕ Half-Marathon (Sunday, November 20th at 7 AM, 22nd Street and Ben Franklin Parkway)
⎕ Full-Marathon (Sunday, November 20th at 7 AM, 22nd Street and Ben Franklin Parkway)
Name: ______Date of Birth*: ______
Signature: ______Date: ______
E-mail Address: ______Phone: ______
Signature of parent/guardian if under 18*: ______
Print Name: ______
* Minimum Age Requirements for Races: Rothman Institute 8K (12 years old), Half-Marathon (14 years old),
and Full Marathon (16 years old). Participants may be required to present proof of age to race organizers.
CREDIT CARD INFORMATION:
Card Type: ______Card #: ______Exp. Date: ______
CSV: ______Name on Card: ______
Address: ______City/State/ZIP: ______
Please email or fax this form to:
Michelle Smolka | Director of Development
Ready, Willing & Able
| F215.732.7441