By becoming a member of Team Groundswell you commit to donate or raise funds of $2,500 for the benefit of Groundswell Community Mural Project- a designated Charity Partner of the ING New York City Marathon 2009. Your credit card information is required as a guarantee against this commitment. In addition to the $2,500, you will be responsible for normal marathon entry fees. $250 will be charged to your credit card to secure your spot upon submission of this application. On 10/15/09, your credit card will be charged $2,250, less any payments received from your donors by that date. You understand that your guaranteed entry and participation in the ING NYC Marathon 2009 is contingent upon this payment schedule. All donations are deductible to the full extent of the law. If you decide to leave Team Groundswell for any reason, you will still be charged the full $2,500.
I have read and hereby agree to the Terms portion of this application.
Name: Organization (if applicable) Address [line 1]: Address [line 2] : City:
Phone: Fax: Email:
Credit Card billing name and address if different from above.
Credit Card (We accept Visa, MC & American Express) Credit Card # Expiration Date
I hereby for myself and all affiliates, release Team Groundswell, Groundswell Community Mural Project and/or its employees, representatives, or affiliates, from and against any and all rights and claims for damages, losses, costs, expenses, injuries, and liabilities resulting from or in connection with participation in the 2009 ING NYC Marathon. I also attest that I will not sue or make claim against Groundswell Community Mural Project for any aforementioned claims. I affirm that I am physically fit and prepared for participation in a marathon and have consulted with a physician regarding this event. I grant permission for Groundswell to use my name and/or photograph in any print/web/telecast promotional materials relating to the event. I understand that I am responsible for donating or raising a minimum of $2,500 for Groundswell and that my credit card will be charged for the remaining balance if I fail to do so by October 15, 2009. I have read and hereby agree to the Waiver portion of this application.
