2017 Boston Marathon Team
Charity Bib Application
All pages of the application must be completed and received by Wednesday, November 16, 2016.This form has been formatted so that it may be filled out electronically, but handwritten signatures are required.Applications are accepted in hard copy format, emailed if signed and scanned, or via fax.
Please note, this is a highly competitive process. Please fill out the entire application fully and carefully.
Send a hard copy of the signed and completed application to:
Boston Health Care for the Homeless Program
Attn: Alyssa Brassil,
Manager of Special Events & Annual Fund Planning
780 Albany Street
Boston, MA 02118
Or sign, scan and email to:
Or sign and fax to: 857-654-1096
Questions? Email:
Please print clearly
Full Name:
Home Address:
City: State: Zip:
Home Phone: Cell Phone:
Email Address:
Employer: Title:
Work Address:
City: State: Zip:
Work Phone: Work Email (optional):
Affiliation with BHCHP: Staff Member Donor/Volunteer
Friend of Staff Member/Donor:
Other: New to BHCHP
Does your company have a matching gift program? Yes No
(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 the race date. If the company’s match cycle is past the race date, or for some reason, BHCHP does not receive the matching gift check prior to the fundraising deadline, the match cannot count towards your minimum.)
I would prefer to be contacted at: Home Work
Running Experience
How often do you exercise?
5-7 times/week3-4 times/week less than 3 times/week
Are you an active runner? Yes No
If yes, how often do you run and what is your weekly mileage?
Can you run at least 7-8 miles?YesNo
Have you ever run a marathon?Yes No
If yes, when and where was the marathon?
Did you complete it? Yes No
What was your time?
Have you ever run a half marathon?Yes No
If yes, when and where was the half marathon?
Did you complete it? Yes No
What was your time?
Please describe your experience in participating in athletic events, both for charity and recreational purposes.
Do you have any prior injuries or specific reasons to be concerned about your ability to complete a marathon? If yes, please explain.
Fundraising Experience
Have you ever participated in a marathon/road race charity program before? Yes No
If yes, for which charity and how much money did you raise?
Charity Name: Amount raised: $
What fundraising strategies did you use?
What will yourfundraising goal be for the BHCHP team?$
(Please keep in mind, each bib recipient is expected to raise a minimum of $7,500. However, runners through the John Hancock Charity Program raised an average of more than $10,000each. Please be ambitious, but realistic, in setting your fundraising goal.)
What are your plans for raising these funds? Please explain your anticipated fundraising plans and activities, including a timeline for reaching your goal.
About You:Please answer the following questions so that we can get to know you a little better.
How did you learn about the BHCHP Marathon Program?
With which other community organizations are you involved, and in what capacity?
Do you have any fundraising experience? If yes, please describe.
Please describe why you would like to run the marathon for the BHCHP team.
Do you see yourself becoming involved with BHCHP after the marathon? If yes, how?
BHCHP will also be holding periodic Team BHCHP events and meetings. Do you foresee any conflicts in attending these events? Yes No
If yes, what is the reason?
Are there any other things that you would like to tell us about yourself as we consider your application?
Signature of Applicant: ______Date:
For the2017 Boston Marathon
Selection and Participation Information
General Information: Boston Health Care for the Homeless Program (BHCHP) has been fortunate to have received the generous contribution of non-qualifying charity marathon bibs from the John Hancock Boston Marathon Non-Profit Programfor the 2017Boston Marathon. These numbers will be assigned to runners who are not time-qualified for the Marathon based on each applicant’s responses on the BHCHP application.
To be considered for selection to Team BHCHP for the 2017 Boston Marathon, individuals must complete an application, agree to the terms described below and sign theRelease Form and Contribution Agreement included in this document. It is important that you tell us as much as possible about why you want to be a member of Team BHCHP for the 2017 Boston Marathon. The more information you provide to us as to why supporting the work of BHCHP is important to you, how you know you will meet your fundraising goals, and what makes you confident that you can complete the Boston Marathon, the better your chances are for being selected to join our team.
Steps to Apply:
Read carefully and agree to BHCHP Selection and Participation Information
Return your completed application by Wednesday, November 16, 2016.
Please keep a copy of these documents for your records.
Benefits of Participation: We are grateful for the time, energy and commitment of runners participating as members ofTeam BHCHP for the 2017 Boston Marathon. To support team runners on the path to successfully completing the marathon, extend our gratitude for their dedication, and assist them in meeting/surpassing their fundraising goals, BHCHP will offer:
A guaranteed race number for the 2017 Boston Marathon on April 17, 2017,
An exciting opportunity to join an enthusiastic team committed to improving the lives and health of our community’s most vulnerable men, women and children,
A packet of fundraising tips and strategies,
Assistance from BHCHP’s Development Team to ensure success in personal fundraising efforts, using the following suggested benchmarks as guidelines:
By January 1, 2017 / $2,500 raisedBy February 14, 2017 / $4,500 raised
By March 29, 2017 / $6,000 raised
By April 17, 2017 / $7,500+ raised
A membership to the L Street Running Club, which has a marathon training program and group runs led by seasoned runners,
A team singlet to be worn on race day,
Motivational and team-building events, includingTeam volunteer night, a Team Dinner, and Pep Rally prior to the marathon,
A personal on-line fundraising page to track progress and receive sponsorships.
Team Selection: Each application is reviewed and considered carefully, particularly as to the applicant’s personal connection to BHCHP’s mission, their fundraising goals, their fundraising plan, and their running experience and ability.
Wait List: During the selection process, BHCHP will compile a wait list of potential runners. If a team member withdraws from the race by the cancellation deadline of December 29, 2016, a wait-listed runner will receive a race entry and will be responsible for raising the fundraising minimum of $7,500.
Fundraising Requirements for Accepted Applicants:
Minimum Fundraising Goal: $7,500.
Non-Refundable Registration Fee: $355. A non-refundable registration fee of $355 will be will be paid by the runner directly to BAA at the time of official registration in January 2017. This payment is solely for your $355 race application fee and does not count toward your fundraising minimum.
Personal Accountability:All accepted applicants are personally responsible for raising the fundraising minimum of $7,500. Credit card information valid through July 2017is required from all accepted applicants. Team members who fail to raise $7,500 by April 30, 2017, will be billed, via their credit card on file, any balance remaining to allow the member to reach the fundraising minimum.Credit card information is completely secure and strictly confidential.
Cancellation Deadline: After December 29, 2016, each participant allotted one of BHCHP’s race entries is responsible for raising the minimum of $7,500, even if the participant is no longer able to train for and/or to run the Boston Marathon. Runners will not be responsible for the fundraising minimum if, after accepting a spot on the team roster, they notify BHCHP in writing by December 29, 2016 that they will be unable to train for and/or to run the Boston Marathon® on April 17, 2017 and BHCHP is able to assign the bib to a new runner commits to raising the fundraising minimum. Donations raised and received by BHCHP by participants who withdraw as a member of Team BHCHP for the 2017 Boston Marathoncannot be refunded, even if the participant revokes their participation before December 29, 2016.
Release Form and Contribution Agreement
Release of Claims
In consideration of my accepting this entry, I hereby, on behalf of myself, my heirs, executor and administrators, release and forever waive, to the fullest extent permitted by law, any and all claims, including claims for injuries sustained by me as a member of Team BHCHP for the 2017 Boston Marathon, that I now have, ever have, or may have against BHCHP, and any of its owners, employees, officers, Board of Directors, attorneys, affiliated entities or agents, including, but not limited to, claims arising under federal, state or local laws, rules and/or regulations, public policy, any claim for breach of contract, contract or tort laws, or any claim arising under statute or common law, such as claims for malicious prosecution, misrepresentation, defamation, false imprisonment, libel, slander, invasion of privacy, negligence, infliction of emotional distress, attorneys’ fees, or otherwise.
Attestation of Physical Fitness
I attest and certify that I am physically fit to train for and to participate in the Boston Marathon and have sufficiently trained for competition in this event. I further attest and certify that a licensed medical doctor has verified that I am physically able to train for and to participate in the Boston Marathon.
Permission for Use of Name, Image or Voice
I hereby grant BHCHP and the Boston Marathon permission for the use of my name and/or photograph and/or voice in broadcast, telecast, print or any other account of the Boston MarathonorTeam BHCHP for the 2017 Boston Marathon. I further agree to waive any compensation that may be due to me for such use of my name, image or voice.
Personal Financial Obligations
As part of my membership inTeam BHCHP for the 2017 Boston Marathon, I agree to the following:
- To collect a minimum of $7,500, with a goal for raising at least $10,000 (“Fundraising Minimum”), for BHCHP by April 30, 2017;
- To remit to BHCHP all amounts raised by me as a member of Team BHCHP for the 2017 Boston Marathon.
- To pay BHCHP any balance owed toward the Fundraising Minimum if I fail to raise and to remit to BHCHP $7,500 by April 30, 2017;
- To permit BHCHP to charge the balance I owe to my credit card on file at BHCHP should I fail to meet the Fundraising Minimum by April 30, 2017;
- To pay BHCHP any balance owed toward the Fundraising Minimum, either by permitting BHCHP to bill my credit card on file at BHCHP or by immediately remitting payment to BHCHP, if I fail to cancel my participation as a member of Team BHCHP for the 2017Boston Marathonin writing by December 29, 2016; and
- To pay the BAA a non-refundable registration fee t of $355.00 at the time of official registration that shall not be applied toward the Fundraising Minimum.
Medical Treatment
I hereby authorize and give my consent to BHCHP to secure from any accredited hospital, clinic, and/or physician any treatment deemed necessary for my immediate care, in the event I suffer an illness, injury or medical emergency arising out of my participation as a member of Team BHCHP for the 2017 Boston Marathon, during the Boston Marathon, or in the training and planning sessions for the Boston Marathon. I further agree that I will be fully responsible for payment of any and all medical services and treatment rendered to me under the circumstances described above, including but not limited to medical transport, medications, treatment, and hospitalization.
Voluntary Agreement
I declare that I have exercised my own judgment in signing thisRelease Form and Contribution Agreement (“Agreement”) and have been afforded a reasonable opportunity to consider its terms and to consult with or to seek advice from any person of my choosing. I further declare that my decision to sign this Agreement was voluntary and not based on or influenced by any representation of BHCHP, its owners, employees, officers, Board of Directors, attorneys, affiliated entities or agents.
I voluntarily and knowingly execute this Agreement by my signature as set forth below.
______
Name (Print)
______
Signature
Date:
Emergency Contact:
The following person should be contacted in the event of an emergency:
Emergency Contact:
Relationship:
Telephone Number:
Email Address:
Medical Allergies:
Printed Name of Applicant:
Signature of Applicant: ______Date:
Credit Card Information:
Card Type (drop down):
Card Number:
Expiration Date: / Security Code:
Name on Card:
Billing Address:
Signature of Card Holder: ______Date:
Boston Health Care for the Homeless Program
2017 Marathon Bib Application
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