2019 Falmouth Road Race Runner Application The application must be completed by Monday, May 27, 2019 at noon Eastern Time. If you have any questions, please contact Taylor Achin at 508-693-7900 x374. Thank you! Date* Name* First Last Email* Cell PhoneAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country T- Shirt / Race Tank SizeSmallMediumLargeExtra LargeEmployer NameJob TitleDoes your company have a Matching Gift Policy? Yes No 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 companies match cycle is past the race date, or for some reason, the Foundation does not receive the matching gift check prior to the race, the match cannot count towards your minimum. It is your responsibility to notify MVCS if we need to supply the employer with any documentation in order to meet this deadlineFundraising ExperienceHave you participated in a road race charity program before?YesNoIf yes, which charity did you run for and how much money were you able to raise?What will you fundraising goal be for MVCS ( minimum required is $1,250)What are you ideas for raising funds? Please explain how you plan to raise the first $250, second $250 and so on.Please answer the following questions so we can get to know you a little better.What is your motivation for wanting to run on behalf of MVCS?What is your connection to MVCS?Have you run this distance before (7 miles)?MVCS will hold meetings once a month for fundraising support, team building, and potential training runs. Do you forsee conflicts in attending these meetings? If yes, please explain.Terms and Conditions for the 2019 Falmouth Road Race Team* I agree to the terms outlined belowPlease read the following carefully before submitting an application. FUNDRAISING COMMITMENT: A minimum of $1,250.00 is required in order to join the MVCS Falmouth Road Race team and receive an individual entry for the 2019 Falmouth Road Race. CANCELLATION POLICY: You may cancel your participation with MVCS team for the Falmouth Road Race, waiving your responsibility for the $1,250 minimum anytime on or before June 1, 2019. To do so, you must contact Taylor Achin at MVCS in writing on or before the cancellation date. Any donations raised and received by our office will not be refunded, even if you cancel before June 1, 2019. After June 1, 2019, you are responsible for raising the $1,250 minimum, even if for any reason, including injury, you are unable to physically participate in the Road Race. RACE REGISTRATION:MVCS will inform you of the details of the Falmouth Road Race registration after your application is accepted. You should NOT contact the Falmouth Road Race organization directly to register. All registration instructions will be provided by MVCS. RELEASE FORM AND CONTRIBUTION AGREEMENT: In consideration of my accepting this entry, I hereby for myself, my heirs, executors and administrators, waive and release any and all rights for claims and damages I may have against MVCS, its employees, volunteers, officers and sponsors for any and all injuries suffered or sustained by me in said event, in the training and planning sessions for said event, or travel to or from any of the preceding. I further attest and certify that I am physically fit and have sufficiently trained for competition in this event. I also grant permission for use of my name and or photograph or voice in broadcast, telecast, print or any other account of this event and agree to waive any compensation for such use. I agree to collect a minimum of $1,250 for MVCS by August 18, 2019, unless prior written arrangements have been made. I understand that unless I cancel by June 1, 2019, MVCS reserves the right to charge the balance I owe to my credit card. I declare that I have exercised my own judgment in signing this agreement and I further declare that the decision to sign this agreement was voluntary and not based on or influenced by any representation of MVCS. In the event of an illness, injury or medical emergency arising during the event or in the training and planning sessions for said event, I hereby authorize and give my consent to MVCS to secure from any accredited hospital, clinic and/or physician any treatment deemed necessary for my immediate care. I agree that I will be fully responsible for payment of any and all medical services and treatment rendered to me including but not limited to medical transport, medications, treatment, and hospitalization. Emergency Contact InfoThe following person should be contacted in the event of an emergency First Last RelationshipCell PhoneAre you allergic to any medications?