Run for the Memory Team – Boston 2012

Alzheimer's Association
311 Arsenal Street
Watertown, MA 02472
800.272.3900

Run for the Memory Team – Boston 2012
All pages of the application must be completed and submitted by Friday, October 14th, 2011.

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Red indicates required fields.

A) Application Type and Contact Information

Non-Qualified Runner Qualified Runner

Last Name:

First Name:

Middle initial :

Address:

City:

State: Zip:

Home Phone:

Cell Phone:

Email:

Employer:

Title:

Work Address:

City:

State: Zip:

Work Phone:

Fax:

Does your company have matching gifts program? Yes No

B) Fundraising Experience

1) Have you participated in a marathon/road race charity program before? Yes No

If yes, for which charity and how much money did you raise. (Please list dates)

1b) Have you ever participated in a Run for the Memory event? Yes No

2) What will your fundraising goal be for the Alzheimer's Association? (minimum donation of $4,000 for a non-qualified runner and $1,750 for qualified runner is required) $

3) How do you plan to meet your fundraising goal?

C) Association/Disease Awareness
(Please answer the following questions so that we can get to know you a little better)

1) How did you learn about the Alzheimer's Association Run for the Memory Boston 2012 Marathon program?

2) Have you had any experience with other Alzheimer's Association's programs? Yes No

If yes, how and which program?

3) What other community organizations are you involved with?

4) Please describe why you would like to run for the Alzheimer's Association.

5) How do you see yourself becoming involved with the Alzheimer's Association after the marathon?

6) Volunteers are critical to the success of our running program. Which event(s) would you be interested in volunteering at in 2012, as part of the Run for the Memory team?

Boston’s Run to Remember (May, 2012)
MA State Triathlon (July, 2012)
Reach the Beach Relay (September, 2012)

D) Running Experience

1) Have you ever run a marathon? If so list date, your finish time and name of marathon?

2) List recent road races, dates, distances and finish times for each race that you have participated in with the last three years.

3) How long have you been running and what is your average running mileage/week?

4) What is your personal running time goal for the marathon?

5) The Alzheimer's Association will be holding regular monthly meetings for group training and planning. Do you foresee any conflicts in attending these meetings? Yes No

If yes, list reasons?

6) List any other fitness physical fitness activites that you are involved in.

Alzheimer's Association Term and Conditions for the Run for the Memory Team – Boston 2012

Please read the following carefully before signing below.

I agree to the above terms and conditions

Name:

Emergency Contact Information

Name:

Relationship:

Phone:

Medical Information

Allergies to medications:

Thank you for applying to the Run for the Memory Team – Boston 2012. We will alert applicants of their acceptance or non-acceptance via email by November 8, 2011

Thank you again.