"*" indicates required fields What type of entry are you applying for?* Charity Entry (I agree to raise a min. of $500) Registered Qualified/Invitational Entry (I agree to fundraise a min. of $250) 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 ApparelPlease 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 StoryIf selected, would you be willing to potentially share your story via social or traditional media outlets?* Yes No Facebook Name Twitter Handle Instagram Username FundraisingIf 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.* $250 (required minimum for registered/qualified athletes) $500 (required minimum for charity athletes) $750 $1,000 $2,000 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?*RunningAre 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 2024 BankNewport 10 Miler:Emergency Contact(person listed cannot be running the 2024 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* MM slash DD slash YYYY
