2023 BankNewport 10 Miler | Joe Andruzzi Foundation

What type of entry are you applying for?*

Charity Entry (I agree to raise a min. of $1,000)
Registered Qualified/Invitational Entry (I agree to fundraise a min. of $500)

Participation Type:*

Registering as a Walker
Registering as a Runner

First Name*

Last Name*

Address*

City*

State*

Zip Code*

Date of Birth*

Cell Phone*

Email Address*

Employer*

Title*

Does your company have a matching gifts program?*

Yes
No

Are you affiliated with the Joe Andruzzi Foundation in any way (ie: corporate member, board member, volunteer, staff, relative or friend of someone working at JAF, etc.)?*

Yes
No

If yes, how?

How did you find out about running the BankNewport 10 Miler for Team JAF?*

Team JAF Alumni
JAF E-Blast
JAF Social Media
JAF Website
Online Search
Word of Mouth
Other

If other, please explain:

Please describe why you would like to run for the Joe Andruzzi Foundation?*

Team Apparel

Please note, runners are required to wear the Team JAF race tank on race day. Please indicate men's or women's and preferred size below (S-3XL).

Official Team JAF Race Tank (typically run small)*

Sharing your Story

If selected, would you be willing to potentially share your story via social or traditional media outlets?*

Yes
No

Facebook Name

Twitter Handle

Instagram Username

Fundraising

If selected for Team JAF, what is your fundraising commitment? Please understand that higher fundraising pledges will be prioritized. If you are selected, this selection becomes your fundraising minimum.*

$500 (required minimum for registered/qualified athletes)
$750
$1,000 (required minimum for charity athletes)
$2,000
$3,000
$4,000

Have you participated in an athletic charity program before?*

Yes
No

If yes, what is the most recent event and how much money did you raise?

What are your ideas for raising these funds?*

Running

Are you in need of any special assistance or are you applying for participation in the disability or visually impaired division?*

Yes
No

If yes, please explain:

If selected, would this be your first BankNewport 10 Miler?*

Yes
No

If no, how many BankNewport 10 Milers have you run and what was the most recent date?

Do you currently belong to a running club?*

Yes
No

If yes, which one?

Do you have any pre-existing injuries or medical conditions that may prohibit you from completing the BankNewport 10 Miler?*

Yes
No

If yes, please explain

Please provide any other information we should be aware of that might impact your ability to train, finish, or fundraise for the 2023 BankNewport 10 Miler:

Emergency Contact

(person listed cannot be running the 2023 BankNewport 10 Miler)

Name*

Relationship*

Home Phone*

Cell Phone*

Allergies/ Medications

Terms & Conditions

I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this application.

I have read through the terms and conditions (link on the BankNewport 10 Miler web page) and acknowledge if accepted to the team, I will be required to sign a document confirming I agree to these terms and conditions.

Signed*

Date*