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2012 Falmouth Road Race Application
Contact Information

Please use your full, legal name rather than a nickname.

Please enter all information exactly as you want it to appear on all correspondence.

2012 Falmouth Flag:
2012 Falmouth Race Entry: *
2012 Falmouth Singlet Size (Sizing and cut are gender-specific): *
2012 Falmouth Fundraising Goal (Minimum $1250 by 9/12/12): * $
Title: *
First Name: *
Middle Initial:
Last Name: *
Suffix:
Nickname:
Address Line 1: *
Address Line 2:
City: *
State: *
Province:
ZIP/Postal Code: *
Country: *
Province:
Phone: *
Email: *
Gender: * Female   Male 
Birth Date: * (mm/dd/yyyy)
Company Name:
Job Title:
Employer Website:
Business Phone:
Business Email:
Fax:
Emergency Contact Name: *
Emergency Contact Phone: *
Emergency Contact Relation: *
Additional Information
Have you participated in other Dana-Farber running programs before? (Check all that apply): * This will be my first running event with Dana-Farber
B.A.A. Half Marathon
Boston Marathon (DFMC)
Chicago Marathon
Falmouth Road Race
New York City Marathon
I chose my own race
Other
If you have previously participated, please indicate when:
How did you hear about the Dana-Farber Falmouth team?: *
I would like to run for Dana-Farber because: *
Other charity participation and fundraising results: *
Recent 10K race, time, date: *
Current & hometown newspaper, town, state: *
Fundraising Agreement and Liability Waiver

If I am accepted as a member of Dana-Farber's 2012 Falmouth Road Race team, I agree to pay a non-refundable, non-transferable, non-fundraising team fee of $30 and to collect a basic fundraising commitment of $1,250 for Dana-Farber Cancer Institute, whether or not I run the race. The deadline for Dana-Farber's receipt of the basic fundraising commitment amount is September 12, 2012. I authorize Dana-Farber to charge the following credit card immediately for my team fee, and on September 13, 2012, for any balance due to meet the basic fundraising commitment. I agree to assume all responsibility for any and all risk of damage or injury that may occur to me as a Dana-Farber participant in the race. In consideration of applying for and being accepted for this event, I hereby, for myself, my heirs, executors and administrators, release and discharge Dana-Farber, Inc., Dana-Farber Cancer Institute, the Jimmy Fund, their employees, volunteers and consultants, the Falmouth Road Race and any and all race sponsors from all claims, damages, rights of action, present or future, whether the same be known, anticipated or unanticipated, resulting from or arising out of, or in incident to, my preparation for and participation in this event. I am aware of the physical demands and hazards of training for and participating in this event, and I am physically fit and will train sufficiently for it. I also grant permission for the use of my name and/or picture in any broadcast, photography or other account of this event.