2010 Chicago Marathon

Team Autism Speaks

Team Application

First Name: ______Last Name: ______

Mailing Address: ______

City: ______State: ______Zip: ______Country:______

Preferred Phone: ______Preferred Email:______

Date of Birth: ______Gender: M or F

Connection to Autism: ______

Singlet/Tank Size (sized for male or female): S M L XL XXL

Long Sleeve Unisex Size: S M L XL XXL

Is this your First Marathon? ______If No, how many have you run before and where? ______

Do you have an entry for Chicago? Y/NAnticipated Finish Time: ______

Name on Credit Card:______

Credit Card Number: ______

Credit Card Type:AmExVisaMC

Expiration Date: ______CSV#(4 digits AmEx; 3 digits V/MC):______

By signing or returning this completed application you are agreeing to the terms of becoming a member of Team Autism Speaks and the fundraising commitment: I authorize Autism Speaks to charge mycreditcard $20 to verify thatthe credit card information/number I providedcan be used to successfully process a credit card transaction. This $20 will be applied to my fundraising total as I agree to raise the minimum fundraising for a position with the team for the 2010 Chicago Marathon.

90 days prior to race day half of all fundraising is required to be reflected online in your personal online fundraising account. If I have notraised $750,I authorize Autism Speaks tochargemy credit card forthe difference between $750 and the amount I am required to raise. At this time I will also re-confirm my commitment to the team and re-verify my credit card information.

The day after the race all money is required to be reflected online. IfI have not raised $1500, I authorize Autism Speaks to chargemy credit card for the differencebetween $1500 and theamount I raised. All accounts must have reached the minimum $1500, the after the race.

A fundraising timeline will be included with the participant welcome email. All team members should be able to demonstrate fundraising capabilities. Failure to meet the fundraising minimum puts your future participation with Autism Speaks marathon teams in jeopardy as we have limited space.

I also understand that my position with the team Autism Speaks is non-transferable. If at anytime I am unable to participate in the marathon I will contact the event managers and they will discuss my options for deferral to the following year, but I am still responsible to raise the minimum amount.

______

Participants Signature(electronic)Date

OFFICE USE ONLY:

Date Received:Date Processed:

Online processing- Y/N

Other: