2019 MDI Application

  • Entry Information

  • Applicant Information

  • Fundraising Experience

  • Please Tell Us About Yourself

  • TERMS & CONDITIONS:

    Registration: After your MDI application has been accepted by Team JAF, you will receive an online link to register through the Joe Andruzzi Foundation (“JAF”). All registrations will be processed directly through JAF.

    Release Form and Contribution Agreement: In consideration of my accepting this entry, I hereby for myself, my heirs, executors and administrator, waive and release any and all rights for claims and damages I may have against JAF and its employees, volunteers, consultants, and product sponsors for any and all injuries suffered or sustained by me in said event and in the training and planning sessions for said event or travel to and from any of the preceding. I further attest and certify that I am physically fit and have sufficiently trained for competition in this event and a licensed medical doctor has verified my physical condition.

    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 $600 ($250 for own entry) for JAF by Monday, October 16, 2019. If I have not reached the amount in donations by that date, I will personally be responsible for the balance owed. I fully understand that the JAF 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 is my own.

    In the situation of a runner who defaults on this agreement and their credit card is not valid for any reason, JAF reserves the right to pursue collection of the debt and the runner will be responsible for any and all legal fees incurred by JAF with this collection process.

    Donations raised and received by our office will not be refunded.

    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 employer has matching gifts. Matching gifts may be applied to the fundraising minimum if received by October 16, 2019. It is your responsibility to contact the company to provide all matching gift information and ensure that the gift is processed. (Policy should be with the section on gift matching)

    Emergency Contact: (Person listed cannot be running MDI) 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 JAF to secure from an 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, medication treatment and hospitalization. The following person should be contacted in the event of an emergency:

  • Please electronically sign below relative to the terms and conditions set forth in the above-mentioned contract. No runner will be considered without providing the required documentation.

    I have received the Joe Andruzzi Foundation MDI application. I understand and agree to all the terms and conditions of my participation in the 2019 program. I understand that the submission of this application does not guarantee me a spot on Team JAF. I acknowledge that the fundraising minimum stated above is due to JAF by October 16, 2019.

  • Please type your full legal name.
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