<p> 2015 Boston Marathon® Non Profit Program Application </p><p>The 119th Boston Marathon takes place on Monday, April 20, 2015. </p><p>Please complete and return all pages of the application by e-mail, mail, or fax to:</p><p>Casa Myrna [email protected] Attention: Development Department P.O. Box 180019 Boston, MA 02118 Phone: 617-521-0176 Fax: 617-521-0105</p><p>This application is for runners who have received a bib for the 2015 Boston Marathon from another source (not through Casa Myrna’s affiliation with the John Hancock Non-Profit Program), and wish to join our team. Runners accepted to join Team Casa Myrna will receive the same access to fundraising support, team uniform and training options as other team members who have received their bibs directly from our organization. </p><p>All applications will be reviewed on a first come, first serve basis. Athletes under consideration for the Casa Myrna Boston Marathon® Team will be contacted directly, as soon as possible. Thank you for your interest! </p><p>Athlete Information</p><p>First Name______Last Name______</p><p>Address______</p><p>City______State______Zip______</p><p>Home Phone______Cell Phone______</p><p>Gender ______Date of Birth ______</p><p>Employer______Title______</p><p>Work Address ______</p><p>City______State______Zip______</p><p>Work Phone______Fax______</p><p>Preferred Email Address______</p><p>I would like to be contacted at: _____Home _____Work</p><p>What is the source of your 2015 Boston Marathon Bib (B.A.A., etc.)?</p><p>______</p><p>Fundraising Experience</p><p>My personal fundraising goal for Casa Myrna in 2015: $______For runners who have received their bibs through other sources, the minimum fundraising requirement for the Casa Myrna Boston Marathon® Team is $1,000. We will provide you with support, ideas and encouragement over the course of the coming months to raise funds for Casa Myrna. </p><p>My company plans to support my efforts: ___Yes, my company has a matching gifts program. ___Yes, my company is able to support my participation through a corporate contribution. ___No, my company does not plan to support my participation. </p><p>I plan to raise funds by (please tell us how you will raise money for your Marathon run; include three specific strategies and who your potential donors are):</p><p>______</p><p>How did you find out about Casa Myrna’s Marathon team? ______</p><p>Why do you want to run for Casa Myrna? What makes this opportunity different from other organizations and causes you support? ______</p><p>Have you done any fundraising for charities in the past? _____Yes _____No</p><p>If yes, please provide the name(s) of the organization(s), the amount(s) raised, and your strategies. ______</p><p>Are you currently involved with other community or non-profit organizations? _____Yes _____ No</p><p>If yes, please describe your involvement (for example, volunteer, donor, Board member, fundraiser, etc)</p><p>______</p><p>Running Experience</p><p>My running level:  Beginner  Intermediate  Advanced</p><p>Current weekly running mileage: Typical training pace (minutes per mile): </p><p>Number of previous Boston Marathons® I have run: ______</p><p>Number of other marathons (besides the Boston Marathon®) I have run: </p><p>Best marathon time/location/date: ______</p><p>Athletic Wear</p><p>Each Casa Myrna Boston Marathon® Team Member will receive a racing singlet. My singlet size is: </p><p>___Men’s Small ___Women’s Small</p><p>___Men’s Medium ___Women’s Medium</p><p>___Men’s Large ___Women’s Large</p><p>___Men’s X-Large ___Women’s X-Large</p><p>Additional Information</p><p>Social networking sites I use: </p><p> Facebook  LinkedIn  Google+  Twitter  Other (please specify): </p><p>Twitter handle: ______</p><p>I have a blog:</p><p> No  Yes, here is the web address: </p><p>Hometown newspaper (please specify town and state): </p><p>Current newspaper (please specify town and state): </p><p>Please be aware that Casa Myrna organizes several events for our runners, including a Domestic Violence 101 training session, team dinners and other gatherings, a visit to one of our shelters, and a team send off/photo opportunity on the morning of the race. Your commitment to attending such events is strongly encouraged. </p><p>As part of Team Casa Myrna, runners will receive a gift bag and uniform, and have access to organized training, with coordinated long runs and injury screening, free of charge. Casa Myrna Terms and Conditions for the 2015 Boston Marathon® Charity Program Please read the following carefully before signing below.</p><p>Fundraising Commitment A minimum fundraising contribution of $1,000 is required to participate in Casa Myrna’s 2015 Boston Marathon® Team, provided that the bib has been received through an outside source (not through Casa Myrna’s affiliation with the John Hancock Non-Profit Program).</p><p>In the event that I do not meet the minimum fundraising requirement by Monday, May 18, 2015, or if I withdraw from the team after January 1, 2015, Casa Myrna Vazquez reserves the right to charge the balance owed to my credit card, up to $1,000 on May 19, 2015. </p><p>Boston Athletic Association Registration and Race Rules The B.A.A. charges a $300 race application fee that does not count towards your fundraising commitment. This fee will be collected separately at a later date. You will be responsible for securing your bib and properly registering with your outside bib source.</p><p>I agree that I will not begin the race prior to the official start time; I will not compete in a manner which, in the judgment of the race officials, interferes with race operations or other participants; and I will not reproduce or transfer my official bib number.</p><p>Cancellation Policy I understand that I may cancel my participation with the Casa Myrna Boston Marathon® Team, waiving my responsibility to raise the $1,000 minimum anytime on or before Thursday, January 1, 2015. To do so I must notify the Development Department at Casa Myrna in writing on or before this date. My $100 deposit fee is non-refundable. After Thursday, January 1, 2015, I am responsible for raising the $1,000 minimum, even if for any reason, including injury, I am unable to run the Marathon.</p><p>Liability I will not hold Casa Myrna responsible for injury or death related to training for, or participating in, the Boston Marathon® as a fundraiser for Casa Myrna.</p><p>I agree to all of the terms and conditions specified above, as evidenced by my signature below.</p><p>______Signature Date</p><p>______Printed Name</p>