Team Lifeline : Go the Distance for Chai Lifeline’s Kids!

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Please use the form below to register online for the Marathon / Half Marathon

When you register, your credit card will be charged a $75 non refundable registration fee. The registration fee signals your intent to raise a minimum of $3,600 to support Chai Lifeline's programs. Approximately 10 weeks prior to the event, you will be required to sign a fundraising recommitment letter. You will have the option to drop out of Team Lifeline until that time, but your registration fee will not be returned. All participants who raise the minimum commitment will have airfare, lodging, and race fees paid for by Team Lifeline.

PERSONAL INFORMATION
First Name:
Last Name:
Email:
Birth Date:
Sex:	Male Female
Address:
City:		State/Prov:
Zip Code:		Country:
Day Phone:		Evening Phone:
Cell Phone:
Employer:		Position/Title:
Education: (last completed)
Emergency Contact:		Emergency Phone:

LOGIN INFORMATION Please create a password in order to collect donations from your friends and family online. You will also be able to view your donation collection status.
Password:
Re-Type Password:

EVENT AND REGISTRATION INFORMATION As a Team Lifeline runner, I support Chai Lifeline and its invaluable programs. I hereby agree to train for and participate in the following event and to raise the designated Fundraising Minimum by approximately two weeks prior to my travel date. Whole Marathon Half Marathon Minimum Commitment: I will be requiring airfare (from within US and Canada) and hotel stay - $3,600. I will not be requiring airfare or hotel stay - $3,000. I will be requiring international travel arrangements - $4,500.
RECRUITMENT INFORMATION How did you hear about the Team Lifeline program? Please identify primary source only: Referred by a Team Lifeline runner (Please Specify) Organization or Club (Please Specify) Newspaper or magazine article Chai Lifeline website Other website HeartBeats or other Chai Lifeline publication / Email
PERSONAL CONNECTION If there is someone in whose honor or memory you wish to train, please indicate below: In honor of In memory of Name: If you would like us to send an acknowledgement of your participation in Team Lifeline to your personal honoree or his/her family, please indicate where the acknowledgement should be sent:

BILLING INFORMATION

The $75 registration fee is waived for Team Lifeline members who ran with us in years past.

Have you previously participated in a Team Lifeline event?
No Yes

What Year?

Card Type:
Card Number:
Expiration Month:
Expiration Year:
Verification Code:
This is the 3 or 4 digit number printed on the back signature panel. It is on the front of the card for American Express.

WAIVER AND RELEASE I wish to participate in the Team Lifeline program to help raise awareness and funds to support the non-profit mission of Chai Lifeline, Inc. I understand that while training for and participating in this event, I will be using public streets and facilities where many hazards exist and I am aware of and appreciate the risks that may result. I am also aware that accidents may occur during this event or during the training for this event, which could result in serious injury or death. I am voluntarily participating in this event and in the training for this event with knowledge of the dangers involved and I agree to accept all risks of injury or death. I have assumed responsibility to raise the minimum fundraising requirement for the event I have selected through Team Lifeline. I agree to collect funds from sponsors and individual donors for my participation in this event that will be donated to Chai Lifeline. Any checks received will be made payable to Chai Lifeline, Inc., with reference to my name and the Team Lifeline event. I will provide all funds collected, whether checks or credit card, on or before the fundraising deadline. I authorize Chai Lifeline, Inc. to charge the credit card submitted during my registration for any balance due to meet the required fundraising minimum established for this event. I am aware that if for any reason, I am not able to participate in the event I will still be committed to raising the fundraising minimum established for the event. In consideration for being permitted to participate in this event to support Chai Lifeline, I agree to assume all risks and to release, hold harmless and covenant not to sue Chai Lifeline, Inc., Camp Simcha, Team Lifeline event team members or captain(s), and any designated beneficiaries, sponsors, officials, participating clubs, communities, organizations, friends of the event, including the event medical sponsor, the medical director, and members of the medical team, and all other government or public entities including, but not limited to, the Department of Transportation and affiliated organizations and all their respective directors, officers, agents, employees and members (collectively, "the releases"), from any claim, loss or liability that I may have arising out of my participation in and training for the event, including bodily injury, death or property damage, whether caused by negligence or carelessness of the releases or otherwise. I intend by the Waiver and Release in advance, and to waive my rights and to discharge all the releases from all claims, losses, or liabilities for death, bodily injury or property damage that I may have, or which may hereafter accrue to me, as a result of my participation in this event, even though that liability may arise from negligence or carelessness on the part of the releases, from dangerous or defective property or equipment owned, maintained or controlled by them or because of the possible liability without fault. I understand and agree that the Waiver and Release is binding on my heirs, assigns and legal representatives. I am physically capable of training for and completing this event. If I am aware of or under treatment for any physical infirmity, ailment or illness, my medical care provider knows of and has approved my training for and participation in this event. I will maintain personal health insurance while training for and participating in the event. I acknowledge that I, and I alone, am entirely responsible for my personal health and safety, and the personal property I bring with me. I understand that all donations processed by Chai Lifeline, Inc. are non-refundable and non-transferable even if I don't participate in the event. I understand that my name, photograph, voice or likeness may be used by Chai Lifeline, Team Lifeline, and their sponsors, beneficiaries, licensees, affiliates and employees. I consent to and authorize, in advance, such use and waive all rights of privacy I have in connection therewith. And I understand that I will not benefit financially from any use thereof. I have carefully read this Waiver and Release and fully understand its contents. I am aware that by accepting this Waiver and Release, I am waiving legal rights and knowing this, I accept it of my own free will. I accept the above waiver and release

Team Lifeline is a non-profit 501c3 organization.