FORM – Racing To Register

What will your age be on race day?*

What is your expected finish time (format must be hrs:min:sec ex. 4:30:25)?*

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Title

Name*

First

Last

Email*

Address*

Address(1)*

Street Address

Address(2)

Street Address Line 2

Address(3)*

City State / Province / Region Postal / Zip Code Country

Phone*

Cell Phone

Gender*

Birthday*

day

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month

/

year

Emergency Contact*

First

Last

Emergency Phone*

Men's Shirt Sizes*

Women's Shirt Sizes*

SHARE INFORMATION ABOUT YOUR EMPLOYER SO WE MAY HELP YOU POTENTIALLY DOUBLE YOUR DONATIONS

My employer offers matching gifts and I want to double my donation?*

Yes

No

Credit Card Type*

Credit Card Number*

Expiration Date*

Security Code*

Name as it appears on the card*

First

Last

NYC Marathon Liability Release

NYC Marathon Liability ReleaseI, (the “Participant”) intending to be legally bound, understand and agree that I am voluntarily participating in Racing To Register, Inc. (“RTR”) TEAM RTR program (the “Program”) and all of its activities including, but not limited to, training for and participating in the following event: (collectively, the “Event”) at my own request and at my own risk. I acknowledge that I am aware of the risks inherent in training for and participating in the Event and certify that I am physically fit, have not been otherwise informed by any physician and know of no restrictions imposed on me by any physician that would in any way prevent me from actively participating in the Event.In consideration of RTR’s sponsorship of this Event and my being permitted to participate in the Event, I, on behalf of myself, my successors in interest, heirs, assigns, and representatives, hereby fully release and hold harmless RTR and its chapters, their Officers, Trustees, agents, employees, volunteers, any medical providers working for or on behalf of the Program, and representatives, successors, and assigns (be they individuals or organizations), together with their insurers and sponsors (collectively, the “Society”), of and from any and all liability, claims, damages, actions and causes of action whatsoever on account of any loss, damage or injury to person (including death) or any other loss or inconvenience whatsoever, suffered by me at any time hereafter arising out of my voluntary participation in this Event, whether resulting from RTR’s negligence or otherwise (collectively, “Liabilities”).I also give permission to RTR to freely use of my name, picture and voice in any broadcast, telecast, print account, or any other account in any medium of this Event (the “Personal Release”). I understand that this Personal Release is perpetual in time and that it encompasses, without limitation, any copyright or right of publicity or privacy that I may have in my name, picture and voice.FUNDRAISING MINIMUMS – Below is the required fundraising minimums for your event. This minimum is set to ensure we keep our program costs low, maintaining our credibility to all of our donors and most importantly, maximizing the funds we are able to invest in our mission. What if I don’t make the minimum? 90 days from race day, or one week from the registration deadline, you will be required to have raised at least 40% of the actual minimum or you will be charged the difference from what is raised and 40%. We will not release your registration code until such time as this is done.You have 30 days after the event to raise the entire minimum. If you have not raised the minimum at the end of 30 days post event you will be charged the difference between what is raised and the minimum requirement.If you exceed the amount of the minimum, or meet it, you can either a) be refunded the amount charged as of the recommitment date or b) leave that amount as a donation to the charity.THE FUNDRIASING MINIMUM FOR THE NYC MARATHON IS $2600*Your submitted credit card info will be charged $15 for registration fees.Registrants pay their own registration fee with the code provided.TEAM members are guaranteed a entry to the race but are responsible for the cost of registration to the eventParticipants acknowledge that should they not raise the minimum fundraising amount or provide a valid form of payment as of the minimum fundraising date, RTR will have no responsibility to provide a race entryExpense reimbursement policies – It is RTR’s policy NOT to: a) Incur meal, lodging or travel expenses that are “lavish or extravagant” or b) Pay the traveling expenses of spouses or other traveling companions.Consent and Information Release (“Consent ”): I hereby grant permission to RTR to render preventative or first-aid assistance or seek treatment or medical care that it seems reasonably necessary, including hospitalization, for my health and well-being. I also give permission to RTR to use and disclose my personal health information (“PHI”) in the ways described in this form. I allow RTR to give out my PHI to doctors, hospitals, ambulance companies, coaches, family members, and others involved in my care and treatment. My PHI may also be used and given out as necessary to run the Event or as necessary for the proper management and administration of RTR. The RTR affirm that PHI will not be used for purposes unrelated to the participant’s health care. RTR will employ all reasonable measures to safeguard and maintain the confidentiality of PHI in its possession.This Release and Consent will be governed by and subject to the laws (except the choice of law principles) and exclusive jurisdiction of the courts of the State of Pennsylvania.Racing To Register and its affiliates shall not be responsible for a cancellation or otherwise delay in a race event and in no case shall the participant be entitled to any refund should an event be cancelled due to an act of god, or natural disaster or otherwise man made incident, injury or otherwise not participating in the event once the liability form herein is signed and submitted.*Must be signed also by parent or legal guardian if the Participant is under age 18 on the date this Release and Consent is signed.I, the undersigned, hereby certify that I am the parent or legal guardian of the Participant, and as such and on behalf of the Participant and I hereby, in accordance with the terms of such Release, release and hold harmless RTR(as defined above) from all Liabilities (as defined above).

(required) I have read and agree with the Liability Release listed above. *

Yes

Signature of Participant*

First

Last

Date