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TEAM BRIGHAM 2011 MARATHON RUNNER APPLICATION GENERAL INFORMATION

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TEAM BRIGHAM 2011 MARATHON RUNNER APPLICATION GENERAL INFORMATION Powered By Docstoc
					                                                  TEAM BRIGHAM 2011
                                             MARATHON RUNNER APPLICATION
GENERAL INFORMATION
NAME___________________________________________________________ BIRTH DATE__________________ GENDER: M or F

ADDRESS__________________________________________________CITY______________________STATE______ZIP___________

HOME PHONE(_____)______________ CELL(_____)_________________HOME E-MAIL*__________________________________

EMPLOYER_____________________________________________________POSITION/TITLE________________________________

WORK ADDRESS_________________________________________________________________________________________________

WORK PHONE:(_____)__________________EXT______ WORK E-MAIL*_______________________________________________

(*Most of our team communication will be via email. Make certain your preferred email does not block attachments. If you do not have
access to email, please indicate.)


SEND MAILINGS/PACKAGES TO (please circle): HOME or WORK                             SEND E-MAIL TO (please circle): HOME or WORK


PREFERRED PHONE FOR CALLS/MESSAGES (please circle): HOME                            WORK      CELL


T-SHIRT SIZE (unisex): S           M       L       XL         XXL        RUNNER SINGLET SIZE: S             M       L     XL       XXL
                                                                         (Go to http://www.raceready.com/misc/sizetech.html for size info)

TEAM BRIGHAM FLEECE (unisex): S                   M       L      XL           XXL


EMERGENCY CONTACT INFORMATION
(For use at training runs and on Marathon Day – please select local person)

Name:_______________________________________________                          Phone Number: ______________________________________

Relationship to Runner (i.e. spouse, mother, father, friend)_________________________________________________________________



TEAM INFORMATION
______ I am a Team Brigham alumnus and ran for BWH in: 1998           1999      2000   2001    2002    2003     2004    2005
                                                              2006    2007      2008   2009    2010 (please circle year/s)

______ I wish to join Team Brigham as a runner supporting community health programs at Brigham and Women’s Hospital.

______ I wish to join Team Brigham as a runner supporting Faulkner Hospital community health programs.

______ I wish to join Team Brigham as a Deloitte & Touche employee/family member/friend.


RUNNING EXPERIENCE/TRAINING INFORMATION/HEALTH BACKGROUND
_____ This is my first marathon.         _______ This is my first Boston Marathon.         _____ I have run _______ marathons.

Preferred time of day to train:____________________

Number of miles/training run:_________ or number of miles run/week ______________


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Specific topics/concerns you would like to have addressed at team meetings: ___________________________________________________
_________________________________________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you have any health concerns we should be aware of?                Yes or No
If yes, please list: __________________________________________________________________________________________________
_________________________________________________________________________________________________________________


Are you currently taking any medications we should be aware of?       Yes or No
If yes, please list:___________________________________________________________________________________________________
_________________________________________________________________________________________________________________


Have you had any recent sports-related injuries that we should be aware of? Yes or No
If yes, please list:___________________________________________________________________________________________________
_________________________________________________________________________________________________________________

ADDITIONAL INFORMATION (use additional sheets, if needed)
How did you learn about Team Brigham?




Why do you want to run and raise funds for Team Brigham (bears impact on acceptance to join Team Brigham)?




What is your personal fundraising goal as a member of Team Brigham (bears impact on acceptance to join Team Brigham)? Each runner commits to
raising a minimum of $3750.




NOTE: Once the above information has been processed and your signed Team Brigham 2011 Acceptance Form and Fitcorp Fitness
Questionnaire received, an email/letter will be sent confirming your status as a member of Team Brigham 2011. The Boston Athletic
Association will distribute Boston Marathon runner bib numbers closer to Marathon Day.



Applicant Signature:______________________________________________ Date:_________________________________________



             TEAM BRIGHAM 2011 APPLICATIONS MUST BE RECEIVED BY November 30
                         Please return this completed document along with your
                Team Brigham 2011 Acceptance Form and Fitcorp Fitness Questionnaire to:

                      Suzanne Leidel, Development Office, Brigham and Women’s Hospital
                              116 Huntington Avenue, 5th Floor, Boston, MA 02116
                     617.424.4309 (phone), 617.424.4370 (fax), or teambrigham@partners.org

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                                           TEAM BRIGHAM 2011 ACCEPTANCE FORM
                                 Please complete all requested information and keep a copy for your records.


I ______________________________________________________________ accept the non-qualifying invitational waiver to participate in the
         (PRINT FIRST AND LAST NAME)
2011 Boston Marathon® as a member of Team Brigham, the marathon team for Brigham and Women’s/Faulkner Hospital.

FUNDRAISING AGREEMENT
As a member of Team Brigham 2011, I agree to raise a minimum of $3750 for community health programs at Brigham and Women’s
Hospital or Faulkner Hospital by May 19, 2011. I understand that should I be injured, or for any other reason, do not run the marathon, I
am still responsible for and agree to pay my minimum fundraising commitment.
In order to participate on the team, I personally guarantee the minimum fundraising commitment with the credit card information listed below. I
understand that my credit card will be charged if I have not met the minimum fundraising requirement due by May 19, 2011. (Please make certain
the credit card number you provide does not expire before the end of September 2011.)

In the event that my minimum fundraising commitment is not met by the May 19, 2011 deadline, I understand and agree to Brigham and Women’s
Hospital charging my credit card for the amount due to meet this obligation. In the event the credit card listed below becomes inactive or otherwise
unavailable for a charge transaction, I agree to immediately provide the Brigham and Women’s Hospital with a replacement card.


          Credit Card Type:       American Express          MasterCard         VISA         Discover

          Card Number:____________________________________________________ Expiration Date:_____________________

          Name as it appears on the card:__________________________________________________________________________
                                                                       (PLEASE PRINT CLEARLY)
          Cardholder’s Signature:________________________________________________________________________________


WITHDRAWAL
I understand that I may withdraw my position on Team Brigham 2011 in writing no later than January 7, 2011. However, I understand that even with
written notice of my withdrawal under the terms of this agreement, I am still responsible for the minimum fundraising commitment. If I am able to
secure a replacement for my position on the team before race applications have been submitted to the Boston Athletic Association, I will then be
released of my $3750 fundraising commitment. I understand my replacement must accept their own minimum fundraising commitment of $3750.
WAIVER
I hereby for myself, my heirs, executors and administrators, waive and release any and all rights and claims for damages I may have against
Brigham and Women’s Hospital, Faulkner Hospital, and sponsors, coordinating groups and any individuals associates with the Team Brigham
marathon program, their representatives, successors and assigns, and will hold them harmless for any and all injuries suffered in connection with this
event. I attest that I am physically fit to compete in this program and all related events to it, and that I am or will be at least 18 years of age on
April 18, 2011. I consent for emergency medical treatment to be given to me should the need arise and that I will be responsible for the cost of such
treatment. Further, I hereby grant full permission to any and all of the foregoing to use my likeness in all media including photographs, pictures,
recordings or any other record of this event and training prior to it, for any legitimate purpose.
I have read this agreement and commitment form carefully, fully understand its terms, and sign it with a release of all liability allowed by the laws of
the Commonwealth of Massachusetts.


Signature:________________________________________________________________                       Date:_____________________________________

                         PLEASE RETURN THIS COMPLETED DOCUMENT ALONG WITH
                       YOUR TEAM BRIGHAM 2011 MARATHON RUNNER APPLICATION AND
                                  FITCORP FITNESS QUESTIONNAIRE TO:

                  Suzanne Leidel, Team Brigham - Development Office, Brigham and Women’s Hospital
                                  116 Huntington Avenue, 5th Floor, Boston, MA 02116
                        617.424.4309 (phone), 617.424.4370 (fax), or teambrigham@partners.org


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                     Fitcorp Marathon Training Program—Team Brigham 2011
                               Physical Activity Readiness Questionnaire (PAR-Q)

                    COMPLETE ALL INFORMATION AND RETURN TO SUZANNE LEIDEL
                (fax at 617.424.4370; email at teambrigham@partners.org; mail to Brigham and Women’s Hospital,
                   Development Office – Team Brigham, 116 Huntington Avenue, 5th Floor, Boston, MA 02116)

Name (print) ________________________________________________ Date ___________________________

Work Phone #________________________________ Home Phone #__________________________________

Employer_____________________________________ Email address__________________________________

Emergency Contact _________________________________ Phone ___________________________________

T-shirt size:    □ Small         □ Medium            □ Large          □ X-Large

Are you interested in Fitcorp membership information?             Yes              No

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active
each day. Being more active is very safe for most people. However, some people should check with their doctor
before they start becoming more physically active. Common sense is your best guide when you answer these
questions. Please read the questions carefully and answer each one honestly:

Check YES or NO. Checking YES to any answer will require you to get a physician’s clearance before starting an
exercise program.

YES     NO
                1. Has your doctor ever said that you have a heart condition and that you should only do physical
                   activity recommended by a doctor?

                2. Do you feel pain in your chest when you do physical activity?

                3. In the past month, have you had chest pain when you were not doing physical activity?

                4. Do you lose balance because of dizziness or do you ever lose consciousness?

                5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?

                6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure
                   or heart condition?

                7. Do you know of any other reason why you should not do physical activity?

I have read, understood, and completed this questionnaire. Any questions that I had were answered to my full satisfaction.

Signature ________________________________________ Staff name _____________________________________
             (runner, please sign here)                        (Fitcorp use only)

                       Fitcorp Marathon Training Weather Hotline – (617) 375-5600, ext. 103
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Jun Wang Jun Wang Dr
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