2015Samaritans Marathon Team Application

Contact Information

Name:______Date of Birth:______

Address:______

Employer/Position:______

Email:______

Day Phone:______Evening Phone:______

Questions

Samaritans was awarded twelve bibs by the John Hancock Non-Profit Marathon Program. A key determinant for receiving these bibs was our past fundraising success. Theselection of runners for the 2015 Samaritans Marathon Team will be evaluated based on an applicant’s proposed fundraising commitment/plan, personal story and connection to the organization. Please type your answers to the first three questions on a separate page(responses should not exceed one page in total) and submit them along with this completed form and your $26 nonrefundable application fee. See “Submitting Your Application and Fee Payment” below for more information.

1.Personal Story –Why do you want to run the Boston Marathon on behalf of Samaritans? What significance would running the Marathon for suicide prevention have in your life?

  1. If you are a survivor, will your family feel comfortable with you sharing your personal story?

2.Connection to Samaritans– In what ways are you already associated with the work and missionof Samaritans?

3.Fundraising Commitment & Plan –John Hancock marathon runners raised an average of $9,600last year and there is an expectation that all non-profit runners will commit to at least this level of fundraising.Given that, please tell us:

  1. What is yourpersonal fundraising goal?
  2. How do you intend to reach your goal?Please include a specific fundraising plan.
  3. Have you raised money for a non-profit in the past?For whom and how much?
  4. What do you imagine would be the challenges you’ll face in fundraising?
  5. Do you plan on making a personal donation to your fundraising efforts, and if so for how much?

Marathon team members who do not reach their goal jeopardize Samaritans’ chances of receiving bib numbers from John Hancock in the future. If you are selected, you are committing to make-up any shortfall below your set personal goal. Do you agree?  Yes  No

Have you run a marathon before?  Yes  No

If so, which marathon? Did you run for a charity? ______

If you are selected to be part of the 2015 Samaritans Marathon Team, would you be able to join us for a Team Kickoff Event on Monday, November 17that the Samaritans Boston Office (41 West Street, Boston, MA, 02111) from6:00-8:00pm? Yes No

Submitting Your Application and Fee Payment
Please email your completed application to Eve Rabinowitzby email at , by fax at 617-247-0207, or mail it to the Samaritans: Attn: Eve Rabinowitz, 41 West Street,4th Floor, Boston, MA 02111. Checks should be made out to “Samaritans”. If you are submitting your application via email or fax, please pay the $26 nonrefundable application fee at:

Please contact Eve Rabinowitz at or 617-536-2460 x 5233 for application deadlines.