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2024 Newport Night Run

"*" indicates required fields

What type of entry are you applying for?

Charity Entry (I agree to raise 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 2024 Newport Night Run 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?*

$250 (required minimum for registered/qualified athletes)

$500

$750

$1,000

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 Newport Night Run?*

Yes

No

If no, how many Newport Night runs 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 2024 Newport Night Run?*

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 Newport Night Run:

Emergency Contact

(person listed cannot be running the 2024 Newport Night Run)

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 Newport Night Run 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