FIRST NAME:

*

LAST NAME:

*

E-MAIL:

*

GENDER:

Female Male *

DAY PHONE # (xxx-xxx-xxxx)

*

CELL PHONE # (xxx-xxx-xxxx)

*

PROFESSION:
Student (area of study):

ARNP ATC DO DPM EMT IV-RN LMT LPN MD PA PT PTA RN Medical Records Student *
N/A ATC LMT Med. Nursing PT

SPECIALTY:
(Sports Med, Ortho, Cardiology, etc.)

*

PROFESSIONAL LICENSE #:
(if applicable)

*

SHIRT SIZE:

S M L XL XXL *

MAILING ADDRESS:

*

CITY:

*

STATE:

*

ZIP CODE:

*

Please answer the following questions:

Running/marathon experience?

Y N

Previous marathon medical volunteer experience?

Y N

Nurse or EMT w/ IV experience?

Y N

* MEDICAL VOLUNTEER WAIVER

By checking this box you acknowledge that you have read and understand the terms within the Medical Volunteer Waiver. If you have not read the waiver, please do so prior to checking this box.

We ask that you print, sign and bring the Medical Volunteer Waiver along with copies of your driver's license and professional credentials (Professional License, Registration, Certification, etc) to the Medical Volunteer Meeting/Orientation prior to the Marathon. The date will most likely be the evening before the Marathon. Please visit the Updates website for information as we approach our race date.

MESSAGE: