2021 Race for Rehab Boston Marathon Application

Applications are open!

Name*

Title First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Enter Email Confirm Email

Gender*

Birthdate*

Employer*

Job Title*

My employer is a matching gift company*

Entry Application Type*

I’m applying to run the Boston Marathon on Monday, October 11th and need an entry.
I have a confirmed entry from the B.A.A. through a qualifying time or another source.

Please specify the source of your official number:*

I have been a member of Spaulding's Race for Rehab team in the past:*

If so, please specify the year(s):*

I am a Spaulding employee:*

If so, please list years employed by Spaulding and facility:*

I heard about Spaulding's Race for Rehab team from:*

If being referred by a staff member, alumni or former patient, please include his/her name.

I would like to run for Spaulding because:*

Describe your personal connection to Spaulding and/or rehab medicine. Please be specific in your response.

My fundraising goal is:*

$7,500
$10,000
$25,000

Note that there is a $7,500 fundraising minimum. Qualifiers and those with their own guaranteed entry have a reduced fundraising minimum of $2,500.

My proposed fundraising strategy is:*

My other charity participation and fundraising experience includes:*

Please list events/races/rides participated in, total amount raised and the year.

I am applying to this year’s team with a friend/family member*

If so, please list the name of each family member:*

Is this your first marathon?*

If not, please list which marathons and how many you have run:*

Are you available to train locally with the team? Our team runs are typically held on select Saturdays.*

Race singlet size:*

Please note we offer men's and women's sizes from S-XXL. The singlets run small and we encourage you to select at least one size larger than you typically wear.

Shoe size:*

Emergency contact name:*

First Last

Relation to emergency contact:*

Emergency contact phone number:

Please read the following rules and requirements carefully before electronically signing below:

I, the "Participant," wish to participate in the 2021 Boston Marathon, being held on Monday, October 11, 2021, as a member of Spaulding Rehabilitation Hospital’s Race for Rehab Team. If I am accepted, I agree to raise and/or contribute a minimum of $7,500 to Spaulding and will be personally responsible for the difference if I fail to collect the required funds by September 30, 2021. To secure my spot on the 2021 Race for Rehab Team, I will set up my personal fundraising page at the direction of team management and will provide a valid credit card with an expiration date of after December 2021. Spaulding Rehabilitation Hospital reserves the right to charge my credit card to achieve all fundraising deadlines. I also understand that Spaulding has the authority to rescind my entrance to the 2021 Boston Marathon at the discretion of team management for misconduct and/or inadequate fundraising.

I understand that I may cancel my participation with Spaulding's Race for Rehab Team prior to June 15, 2021 by contacting Amanda Shuman, Assistant Director of Corporate Partnerships and Special Projects at alshuman@partners.org or 617-952-6885. Funds raised will not be returned or refunded under any circumstance. I understand and agree that injury, illness, travel complications and force majeure prohibiting my participation in — or completion of — the 2021 Boston Marathon after June 15, 2021, does not exempt me from the fundraising requirement and I will be responsible for all fundraising commitments.

In addition to the fundraising requirement, I am responsible for covering the race registration fees, to be paid directly to the Boston Athletic Association and acknowledge that this does not count towards my fundraising goal. Entries are non-transferrable and cannot be deferred to a future year under any circumstance. By signing below, I also agree to all terms and conditions of the Boston Marathon set forth by the Boston Athletic Association.

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 Spaulding, 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 from any of the preceding. I further attest and certify that I am physically fit — verified by a licensed medical doctor — and will sufficiently train for competition in the event. I also grant permission for use of my name, photograph or voice in broadcast, telecast, print or any other account of this event — indefinitely — 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 Spaulding.

In the event of an illness, injury or medical emergency during the 2021 Boston Marathon — or in the training and planning sessions — I hereby authorize and give my consent to Spaulding to secure from any accredited hospital, clinic and/or physician any treatments deemed necessary for my immediate care. I agree that I will be fully responsible for payment of any and all medical services and treatments rendered to me including but not limited to medical transport, medication, treatment, and hospitalization.

I agree with the above statement*

I agree

Electronic Signature*

First Last

Today's date:*