Run for the Children® Official NACoA Registration Form Detroit Free Press/Flagstar Bank Marathon – October 19, 2008
Last name __________________________ First name ___________________________ Middle initial _____ Address __________________________________________________________________________________ City _______________________________ State ______ Zip ____________ County _______________________ Date of birth (MM/DD/YY) ___________________________ Age on Race Day ____________
(circle one) Gender M / F
U.S. Citizen? Y / N
Military Service? Y / N
Day phone _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ E v e n i n g p h o n e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ E-mail Address_____________________________________________________________________________
___ ___ ___ ___ ___ ChampionChip # (if you own your chip) _______________________
(check applicable) ____ Full Marathon
Anticipated time for this race
_____5 person Relay Team
Team member names
1______________________ 2______________________ 3______________________ 4______________________ 5______________________
To expedite planning and reservations please complete the following:
_ _ _ _ _ N o I w i l l b e a t t e n d i n g t h e P a s t a D i n n e r a n d R a l l y o n 1 0 / 1 8 / 0 7 . O n e g u e s t i s i n c l u d e d a t n o c h Yes _____ a r g e . _____additional attendees (guests @ $25/ea.) Total attendees _____
Waivers and Disclaimers
I have full knowledge of and assume the risks (heat exhaustion, heat stroke, personal injury, etc.) involved in training for and participating in the NACoA Run for the Children® in the Detroit Free Press/Flagstar Bank marathon as indicated on the registration form. I represent that I am physically fit and sufficiently trained to participate therein. Because you are relying on these representations and in consideration of your accepting my entry into the Marathon, I, for myself, my executors, administrators and assignees, do hereby release and discharge the National Association for Children of Alcoholics, sponsors of the NACoA Run for the Children®, and the respective officers, directors, agents and employees of the foregoing jointly and separately, from and against any and all actions, claims, demands or damages which in any way arise out of or result from my training for or participating in the Marathon or any Marathon-related events. I further agree you may subsequently use for publicity and/or promotional purposes, without any obligation or liability to me, my name and any photo of my participating in the Detroit Free Press/Flagstar Bank marathon as indicated on the registration form. I have carefully read and do understand the foregoing Waiver and certify that I am signing it of my own free will.
I agree to the above waivers and disclaimers.
Participant’s signature ____________________________________________________
Parent or Guardian's signature is required if participant is under 18 years of age _____________________________________________________ Date ____________
All participants are required to provide a credit card number upon registration. _____ VISA ______ MasterCard ____American Express Credit Card #: _______________________________________________________ Credit Card Security Code:__________ Expiration date: ________________
______My commitment check for $150 is attached.
_____I authorize you to charge my commitment fee at this time. Signature: _________________________________________________________________________
I understand my credit card will be charged for the outstanding amount below the fundraising minimum required ($1000 or $750 per team member) by race day. I authorize you to charge my credit card for the balance of the minimum amount required not raised by race day.
Signature _________________________________________________________________________ Upon receipt of your registration commitment, you will receive a complete TEAM NACoA packet with all the materials and information you need to do your fundraising and to get started preparing for NACoA’s Run for the Children® in the Detroit Free Press/Flagstar Bank Marathon.
Thank you for your commitment to help the children and families hurt by alcohol and drug abuse.