EmailMe Form - 2022 Falmouth Road Race

Personal Information

Name *

First MI Last

Email *

Primary Phone Number *

### - ### - ####

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Date of Birth *

MM / DD / YYYY

Proof of Photo Identification

Please upload a photo/copy of your Driver's License.

*If you are unable to upload this now, please email it to Cherylann@BeLikeBrit.org

Health Information

Do you have any Environmental Allergies?

If yes, please list each allergy.
If no, please write N/A.

Do you have any Allergies to Medications?

If yes, please list each allergy.
If no, please write N/A.

Do you have any of the following Medical Conditions? *

Please select all that apply.
To select more than one option, hold down "ctrl" or "command" (for mac) on your keyboard.

Do you have any other Medical Conditions?

Please list any other conditions not listed above.
If no, please write N/A.

Have you had any previous Sports-Related Injuries?

Please list any sports-related injuries.
If no, please write N/A.

Additional Information

Does your company have a Matching Gifts Program?

Yes

No

I don't know

See below for more information on matching gifts program.

Would you like a running t-shirt or tank top? *

T-Shirt

Tank Top

Please choose which you would prefer to wear on Race Day.

Shirt size *

Running Experience

Have you run a timed race before? *

Yes

No

If yes, please include the race information for your most recent race below.

Length of Race (5K, 10K, etc.)

Finishing Time

Pace per Mile

If you have not run a timed race before, please include your average pace per mile when recreationally running.

Have you participated in a Marathon/Road Race Charity Program before?

Yes

No

If yes, please include the charity name and amount raised below.

Charity Name

$ Amount Raised

Getting to Know You

What will your fundraising goal be for Be Like Brit? *

What are your ideas for raising these funds? *

(Emailing friends & colleagues? Facebook campaign? Are you part of a club or organization you could share with? etc)

How did you learn about Be Like Brit Race Team? *

Please describe why you would like to run for Be Like Brit. *

Emergency Contact Information

Please be sure to list someone who will be available on Race Day.

Name *

First Last

Phone *

### - ### - ####

Email

Important Information

Please read the following information carefully before signing below:

Registration Fee

Be Like Brit requires a non-refundable registration fee of $100 which includes a BLB running performance shirt and access to a personal fundraising website. This registration fee does not count towards your fundraising commitment. You will be required to submit your $100 registration fee once you have been accepted onto the team, via the link provided to you in your acceptance email. Your payment confirmation email will verify your acceptance. The deposit of $100 holds a Falmouth Road Race number in your name.

Fundraising Commitment

To participate with the BLB Race Team and receive an entry for the 2022 Asics Falmouth Road Race, each runner is committed to raise a minimum of $1,000 prior to race day. In the event that you do not meet the fundraising commitment requirement by that date, you will have 30 days to continue fundraising to make up the remaining balance. After the 30 days, Be Like Brit reserves the right to charge the balance owed to your personal credit card, unless prior arrangements have been made and agreed upon.

Matching Gift Policy

Many companies match employee charitable contributions. You can check with your employer to see if your company has this program, and ask donors if their employers match gifts. Many companies issue matching gift checks quarterly or semi-annually: therefore if you plan to use a match to reach your minimum, it is your responsibility to contact the matching company to ensure the check will be issued before August 15, 2022.

Release Form and Contribution Agreement

In consideration of my accepting this entry, I hereby for myself, my heirs, executors, and administrators, waive and release any and all rights for claims and damages I may have against Be Like Brit, its employees, volunteers, officers, and sponsors for any and all injuries suffered or sustained by me in said event, in the training and planning sessions for said event, or travel to or from any of the preceding. I further attest and certify that I am physically fit and have sufficiently trained for competition in this event, and a licensed medical doctor has verified my physical condition. I also grant permission for use of my name and or photograph or voice in broadcast, telecast, print, or any other account of this event and agree to waive any compensation for such use. I declare that I have exercised my own judgment in signing this agreement and I further declare that the decision to sign this agreement was voluntary and not based on or influenced by any representation of Be Like Brit.

In the event of an illness, injury or medical emergency arising during the event or in the training and planning sessions for said event, I hereby authorize and give my consent to Be Like Brit to secure from any accredited hospital, clinic and/or physician any treatment deemed necessary for my immediate care. I agree that I will be fully responsible for payment of any and all medical services and treatment rendered to me including but not limited to medical transport, medications, treatment, and hospitalization. The following person should be contacted in the event of an emergency:

Agreement *

I certify that I agree to the above listed terms as defined in sections "Registration Fee," "Fundraising Commitment," "Matching Gifts Policy," and "Release Form and Contribution Agreement."

Signature

Full Name of Runner (Type) *

Signature (Write with your Mouse)

Clear

Email