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1 C360: Reg Fee: 1:1: Team In Training Non-Waivered Participant Application First Name: Last Name: Home Address/P.O. Box: City: State: Zip: Primary Phone Number: Secondary Phone Number: Home Work Mobile Home Work Mobile Personal Work Employer: Position/Title: Sex: Male Female Birth Date: / / Education (last completed): High School College Post Graduate I would like to receive advocacy updates to learn how else I can assist in the fight against blood cancers. EVENT AND REGISTRATION INFORMATION As a Team In Training volunteer supporting The Leukemia & Lymphoma Society and its mission, I hereby agree to train for and participate in the Boston Marathon on April 21, 2014 and to raise the designated fundraising commitment by the event recommitment date. Non-Waivered Runner $4, fundraising commitment I understand the fundraising deadline is January 31, If I have not reached the minimum by that time, I will be charged the balance to reach $4, to register for the race. I am able to continue to fundraise through May 21 st to be reimbursed for anything charged on January 31 st. REGISTRATION FEE AND PAYMENT INFORMATION I have enclosed a check for my $150 non-deductible, non-refundable registration fee, made payable to LLS. Check will be cashed upon acceptance to the team. Please charge my credit card for the $150 non-deductible, non-refundable registration fee. Card will be charged upon acceptance to team. Card Number: Expiration Date: Security Code: Name as it appears on the card Signature If I am not selected for the team, I would like my registration fee to be a donation in support of The Leukemia & Lymphoma Society s mission. I am a Team In Training Alumni who has met prior fundraising commitments and deadlines Event Name(s): Year(s): Amount Raised: $ $ This will be my first time participating in the Team In Training Program.
2 FUNDRAISING EXPERIENCE Have you done any fundraising before? (Please Circle) Yes No If yes, for what cause and how much did you raise? What were some of the challenges you encountered and how did you overcome them? Does your company have a matching gifts program? (Please Circle) Yes No What is your personal fundraising goal for this program? $ $10,000+ $7,500+ $6,000+ $5,000+ $4,000 What is your strategy to achieve this goal? *TNT is a fundraising program with a training component. This is the most important part of our program and is the most important section of the application. Please do complete this portion to the best of your abilities. Please highlight your top 3 strategies and how you will accomplish them. Please attach an additional page if necessary.
3 THE LEUKEMIA & LYMPHOMA SOCIETY MISSION How did you hear about the Team In Training Program? Do you have first hand connection to leukemia, lymphoma, Hodgkin s disease, myeloma or other type of cancer? If not, why would you like to run for Team In Training? (Attach additional page if necessary.) How do you see yourself becoming involved with The Leukemia & Lymphoma Society after the Marathon? PATIENT AMBASSADOR I understand that I will be training and participating in honor of the Team In Training Boston Marathon Patient Ambassador (a blood cancer patient or survivor) and/or may select my own personal honored individual(s) to run for. If participating in honor or memory of someone else, please provide their information. Honor or Memory Name: Age: Diagnosis: Honor or Memory Name: Age: Diagnosis: Do you think this person would be interested in joining the team as an Patient Ambassador? Yes please contact me They are not interested at this time Are you a survivor/patient? Would you be interested in participating in the capacity of a Patient Ambassador? Yes please contact me I am a survivor, but I am not interested at this time
4 MEDICAL AND FITNESS INFORMATION Your medical information will be shared with the TNT to ensure our athletes are safe at training and race weekend. FITNESS/MARATHON EXPERIENCE I currently engage in athletic activities: Daily 5-6 Days/Week 3-4 Days/Week 1-2 Days/Week Seldom Have you completed a marathon or other endurance sports event before? Yes No If yes, which events? How many of the following have you completed: Marathon(s) Half Marathon(s) 10K(s) 5K(s) Century Ride(s) Triathlon(s) Other: What is your average pace per mile? What was your most recent race? Marathon Half Marathon 10K 5K Other Finish time? What is your goal finishing time for the Boston Marathon? TRAINING AVAILABILITY We will be hosting training runs at 8 AM on Saturday mornings in Wellesley, MA. Do you plan on attending? Yes No Would you be interested in participating in mid-week track workout in/around Boston? Yes No Where will you be doing most of your training? PERSONAL OBJECTIVES What are your fitness goals for this season? To complete the marathon To set a personal record. Goal Time: Personal Best: Improve my overall health and fitness Lose weight Other: MEDICAL CONSIDERATIONS Do you have any medical conditions or pre-existing injuries we should be aware of? Yes No If yes, please explain: I understand that to be an official finisher with the Boston Athletic Association I must be prepared to complete the Boston Marathon in 6 hours. I further understand that if I am still on the course at that time, I could be asked to leave the course. TNT will train all athletes to work towards completing the marathon in the time allotted. Please initial that you agree to the above
5 Full Name: Male Female Home Address: Cell Phone: Birth Date: Age: Medical Insurance Company: Insurance ID Number: Group Number/Name: Current Medications: Condition(s) Requiring Medication: Allergies (all): Have you experienced any of the following symptoms in the past year? If any of the symptom boxes are checked Team In Training requires a note from a physician giving medical permission to participate in any Team In Training program. Asthma Back Problems Fainting Spells High Blood Pressure Liver Condition Heart Murmur Diabetes Trouble Breathing Chest Pain Unusual Fatigue Chronic Illness Heart Condition (please explain) Do you have any conditions that might affect your health and safety while training for the Boston Marathon? Yes No If yes, please explain: Please list any pervious or current athletic injuries: EMERGENCY CONTACT INFORMATION In case of an emergency during Saturday training runs, please notify: Name: Relationship: Primary Phone: Secondary: Home Work Cell Home Work Cell In case of an emergency during the Boston Marathon, please notify: Name: Relationship: Primary Phone: Secondary: Home Work Cell Home Work Cell
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