This document is a participant agreement form for the 2012 Chicago Marathon Mercy Home Heroes team. It requests contact information, emergency contacts, t-shirt and singlet sizes, and whether the participant has already registered for the marathon or needs Mercy Home to provide registration. It includes a release and waiver of liability and a fundraising agreement to raise a minimum of $1000 for Mercy Home, with credit card information in case the minimum is not met.

1. 2012 Chicago Marathon
Participant Agreement
Name: _________________________________________________________________
Address: _______________________________________________________________
City, State, ZIP: __________________________________________________________
Primary Phone: __________________________ Secondary: _____________________
Email: _____________________________________________________
Gender: M F Date of Birth: _______________________
Emergency Contact:
Name:_____________________________________
Phone:______________________________ Relationship:_______________________
Check appropriate box(es)
□ – Yes, I wish to share my name and email on the Mercy Home Heroes team roster.
□ – Yes, I wish to participate with one of Mercy Home’s coaches.
□ Coach - Lakefront
□ Coach - Downers Grove
Please circle your choice:
Training t-shirt size: XS S M L XL Race singlet size: XS S M L XL
Check one box:
□ I am not registered for the Chicago Marathon - Mercy Home will supply my marathon
registration via post-close registration ($150 fee required)*
□ I have registered on the Bank of America Chicago Marathon website and paid my $150
entry fee
Fundraising Goal - Minimum $1000

2. Release and Waiver
In consideration of being permitted in Mercy Home’s 2012 training programs, the Mercy Home Marathon Team
and the 2012 Bank of America Chicago Marathon ("the Events"), I do hereby, for myself, my heirs, executors,
administrators, successors, assigns and personal representatives, waive and release any and all rights, claims
and causes of action I have or may have against: Bank of America N.A. and its affiliates, Chicago Event
Management Inc., the City of Chicago, the Chicago Park District, all governmental bodies or districts
representing the area(s) in which the race is held, the Bank of America Chicago Marathon, Mercy Home for Boys
& Girls, and their affiliates, agents, employees, officers, representatives, directors, successors, and assigns of
each of the foregoing, and all other persons connected with this program, that may arise as a result of my
participation in any of the Events and any pre- and post-race activities. I further grant full permission to any and
all of the foregoing to use and reproduce my image or likeness by any audio and/or visual recording technique
(including electronic/digital) now in existence or hereafter invented, for any legitimate purpose, including
commercial sales and marketing purposes. I am physically fit and my physical fitness has been verified by a
licensed medical doctor and I am sufficiently trained to participate in the Events and recognize the risks
involved, and intend by this release to assume full responsibility for anything that might happen to me.
Signature:__________________________________ Date:___________________
Fundraising Agreement:
By registering for the Mercy Home Heroes Marathon Team:
I agree to raise a minimum of $1000 for the kids at Mercy Home for Boys and Girls, minus applicable credits*.
The full amount is due by November 8, 2012. If I have not submitted the balance of my minimum pledge
amount on or before November 8, 2012, I authorize Mercy Home for Boys & Girls to charge the balance of the
minimum pledge amount to my credit card on November 9, 2012.
I understand that unless I notify Mercy Home of my withdrawal from the Chicago Marathon before July 31, 2012,
I will be responsible for the minimum pledge amount.
Signature: ________________________________ Date: ________________________
Credit Card Number____________________________CVV/Security Code __________
Credit Card Expiration Date_______________________ □ Visa □ Master □ American Express
Please return completed and signed registration to:
Mercy Home for Boys & Girls
Attn: Amber Cerveny
1140 W. Jackson Blvd
Chicago, IL 60607
ambcer@mercyhome.org
Or you may fax all forms to 312.738.9250