DONOR APPLICATION FORM STANDARD CHARTERED MUMBAI MARATHON 2017
Sunday, 15th January 2017
APPLICATION FORM for CHARITY RUNNING BIBS For Race Category: Dream Run, Senior Citizens' Run & Champions with Disability
This application form is only meant for applicants who wish to participate in the Standard Chartered Mumbai Marathon 2017 by availing a charity
running bib in support of an NGO which is registered for the Event with United Way of Mumbai (UWM), Event's official Philanthropy Partner. The
charity running spaces are available at a premium, the minimum contributory amount being ` 9,000, the amount so contributed/raised by the
applicant will go to the chosen NGO after deducting applicable Event application fees mentioned below, depending upon the race category
chosen by the applicant, and INR 150 being processing charges retained by UWM. For information on the list of participating NGO's who have
such charity running numbers on the offer and for rules guiding availability of such numbers, log on to www.unitedwaymumbai.org/scmm.
Though not mandatory, all applicants are encouraged to raise funds for NGOs of their choice among those registered with UWM for the Event.
Please visit www.unitedwaymumbai.org/scmm.
End date for Charity Running Bibs application: 18th November 2016 or until charity running places are filled, whichever is earlier.
RACE CATEGORIES
Race/Distance
Min. Age Eligibility
Dream Run (6 km)
Born on or before 14.01.2005 (12 yrs)
Sr. Citizens' Run (4.3 km)
Born on or before 14.01.1957 (60 yrs)
Champions with Disability (2.5 km)
Born on or before 14.01.2005 (12 yrs)
Important Information for Dream Run , Senior Citizens' and Champions with Disability applicants
Group entries: More than 35 entries from any single group/entity or association, will NOT be accepted.
Group entries: A covering letter (as per the format available online on www.scmm.procamrunning.in) on a company/NGO/ any
entity's official letterhead and a copy of company/ NGO/ any entity's PAN Card need to be submitted along with the forms. Refer
to Entry rules & Guidelines for more details.
Do not submit marathon and half marathon applications along with group entry for the Senior Citizen or Champions with Disability
categories. All applications within the group will not be accepted.
Applicants below 18 yrs can submit their identity card issued by their school / college.
Champions with Disability: Participation in the Champions with Disability is open for individuals with the following disabilities:
physical/locomotor disability, intellectual impairment, visual impairment, hearing impairment and orthopaedic or neurological
disorder.
A duly filled application form needs to be submitted with a copy photo ID proof i.e. either passport, PAN card, or Aadhaar card.
No Goodie bags will be given.
scmm.procamrunning.in
/scmumbaimarathon
@runscmm
Dream Run, Senior Citizens' Run &
Champions with Disability
EVENT APPLICATION FEES (included in donation amount)
Applicant type/Fee constituent
(inclusive of Service tax)#
Domestic Applicants
(applicants residing in India)
Overseas Applicants
(applicants residing outside India)
Dream Run
Sr. Citizens' Run
Champions with
Disability
` 800
` 350
` 350
USD 30
USD 15
USD 15
# Procam Intenational's Service Tax No. AABCP7300EST001 & CIN No. U92413MH1993PTC070636
PAYMENT MODES OF DONATION AMOUNT
Cheque (Only local Mumbai cheques will be accepted)
Note:
(i) All donation cheques to be drawn in favour of “UNITED WAY OF MUMBAI”,
(ii) Please write your full name, the race category chosen and contact number on reverse of cheque,
(iii) The donation amount includes the event application fees, as per the chosen race category, and administrative fees of United Way of Mumbai.
ARE YOU FIT TO PARTICIPATE?
Please review the following questions before submitting your application form.
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs for your blood pressure or heart condition?Are you pregnant?
Are you diabetic?
Do you know of any other reason why you should not do physical activity?
If you have answered YES to any of the questions above, then please consult your physician before applying for registration in Standard Chartered
Mumbai Marathon. Irrespective of whatever may be your age, we sincerely advise you to obtain a medical clearance from a registered medical
practitioner/doctor before applying for the Standard Chartered Mumbai Marathon 2017. It is unfair to you and your family to risk serious illness and
become a medical emergency on race day.
ENTRY RULES AND GUIDELINES
1) Only one applicant can apply using a single form. Also, do not send in more than one entry per person using this form; multiple applications will
entail all being rejected.
2) Once you have applied for the Charity Running Bibs and have submitted this Application Form, any further application made by you in the normal
modes of application, will be rejected.
3) Photocopies of the Charity Running Bibs Application Form can be acceptable only if attested by United Way of Mumbai
4) Charity Running Bibs Application Form needs to be submitted, by the NGO to whom this form has been allocated to, only at United Way of Mumbai's
office at 309, Nirman Kendra, Famous Studio Lane, Dr. E Moses Road, Mahalaxmi Estate, Mumbai- 400011 (Monday to Friday, 10 am to 6 pm).
This application form will NOT be accepted at any Standard Chartered Bank branches; no other application mode is open for charity running
bibs application form other than submission at United Way of Mumbai office.
5) Before sending in your application, please check if you..
have filled in details against all mandatory fields prefixed with '*' in the application form;
have affixed a copy of your latest colour passport sized photograph on the form;
have attached a copy of either your Aadhar card, PAN card or passport to the form;
have enclosed the requisite application fees (refer to 'application fees' chart);
have signed the 'waiver' in the application form;
have met the minimum age eligibility criteria for the chosen race category.
If applicant is below the age of 18 years, the guardian has also signed the 'waiver' and written his/her relation with the applicant.
scmm.procamrunning.in
/scmumbaimarathon
@runscmm
Dream Run, Senior Citizens' Run &
Champions with Disability
9) Group entries (applicable to Dream Run, Senior Citizens' and Champions with Disability):
a) Where 6 - 35 individuals submit their entries together under Charity Running Bibs, this will constitute a group entry. All members of a group have to fill
and sign individual application forms. Under 'Application Type' in the application form, applicants need to choose 'Group', mentioning the group name
and size of the group;.
10) Application status: Post close of registrations, individual applicant is required to go online on www.scmm.procamrunning.in
application status. If you are unable t o check application status online, please contact our event helpline number +91 22 42020200
or email us at scmm@procam.in
11) Entries not accepted: Participation in the event is subject to entry confirmation. Where your entry is not confirmed for any reason, of the total
donation amount, only the application fees, paid by you will be refunded on or before 31st December 2016. An amount of INR 100 will be deducted
as processing charges. Any refund discrepancies must be brought to the attention of the Event Registration Team immediately. Refund queries will
not be entertained post 31st January 2017. **Note: Only event entry fees will be refunded, Donation amount will NOT be refunded and will be
disbursed by United Way Mumbai to the NGO/s supported by the participant.
12) Requests for cancellation and thereby, refund will not be entertained. Further application fees will not be refunded by virtue to non participation,
including failure by a confirmed participant to collect his/her bib from the Expo.
13) Running number bib collection:
13.1) All confirmed participants/their authorised representatives are required to come to the Get Active Expo in Mumbai scheduled from 06th January
2017 to 08th January 2017 in order to collect their running number bibs. No running number will be posted to individual mailing addresses.
13.2) Authorised representative must carry with him/her (a) print of website confirmation (b) photocopy of photo-identity proof (Aadhar card, PAN card
or passport) of the representative and the confirmed participant.
13.3) Outstation and overseas participants can collect their running number bibs on Saturday, 14th January 2017.
13.4) Venues of Get Active Expo and Outstation Expo will be updated on the event website (www.scmm.procamrunning.in).
14) Confirmed runner's identity and proof of residence may be verified by a verification agency hired for validating the details provided by you in the form.
Where the identity and/or proof of residence of a runner is found incorrect or incomplete, participation of the said runner will be withheld and there will
be no refund of application fees paid by the said runner.
15) All participants' race day images will be screened visually after the race and if any of the participant is found not wearing the running number bib
allotted to him/her, the participant registered for that bib will be disqualified from the race and the subsequent edition of the event in 2018. Further,
Procam International reserves the right to take necessary legal action against the registered participant and the person who has used the running
number bib on race day, for impersonification.
16) For information on awards and accolades, log on to www.scmm.procamrunning.in
17) Please thoroughly go through all information mentioned in this form prior to submitting your application. Confirmation of applications received will be
subject to the applicable Entry Rules & Guidelines given herein.
18) This application form and the right to participate in the event and the rights and benefits available to the applicant under this entry form is at the sole
discretion of the event Promoters, Procam International Pvt. Ltd., and cannot be transferred to any other person under any circumstances. The
applicant alone shall be entitled to the rights and benefits arising out of such confirmation of participation.
19) This application form and the right to participate in the event and the rights and benefits available to the applicant under this entry form is at the sole
discretion of the event Promoters, Procam International Pvt. Ltd., and cannot be transferred to any other person under any circumstances. The
applicant alone shall be entitled to the rights and benefits arising out of such confirmation of participation.
EVENT CONTACT DETAILS
Event Helpline: +91 22 42020200 (Mon to Sat, 10 am to 7 pm)
Website: www.scmm.procamrunning.in
E-mail: scmm@procam.in
Driven by
Nutrition Partner
Supported by
scmm.procamrunning.in
/scmumbaimarathon
@runscmm
Dream Run, Senior Citizens' Run &
Champions with Disability
Jan 15, 2017
Sr. no: ___________
APPLICATION FORM (Charity Running Bibs only)
* Affix your recent
color photograph
with your face
clearly visible
Size: (1.2 inch x 1.2 inch)
For Race Category: Dream Run, Senior Citizens' Run & Champions with Disability
Note: No Goodie bags will be given.
This application form is only meant for donors who wish to take part in the Standard Chartered Mumbai
Marathon 2017, through a non-profit charitable organisation by contributing to his/her chosen cause or NGO.
The charity running spaces are available at a premium, the minimum contributory amount being INR 9,000
(includes event application fees), the proceeds excluding event application fees and UWM processing
charges, going for the benefit of the chosen NGO.
This application form will not be accepted at Standard Chartered Bank Branches or any other application
modes available for General category registrations.
This application form, the donation cheque/s (drawn in favour of “United Way of Mumbai”) and the pledge sheet, needs to be submitted, by the NGO
t o w h o m t h i s f o r m h a s b e e n a l l o c a t e d t o , a t t h e U n i t e d Wa y M u m b a i o ff i c e a t M a h a l a x m i E s t a t e , M u m b a i .
Please fill up the form in CAPITAL letters only
CHECK LIST: HAVE YOU….
w Fully read the information in the overleaf of this Application Form?
w Filled all mandatory fields (marked '*')?
w Affixed your recent passport sized photograph?
w Included the correct application fee?
w Attached a photocopy of your latest timing certificate?
w Signed the Waiver?
w Attached a copy of either your Aadhar card or PAN card or passport as may be applicable
RACE CATEGORY (tick ü any one)
Dream Run - 6 km
Senior Citizens' Run - 4.3 km
Champions with Disability - 2.5 km
APPLICATION TYPE
Individual Entry /
Group Entry
Group Size
Group Name
(Group size not to be more than 35 people)
(Applications under Group will be accepted only for Dream Run, Sr. Citizens' Run and Champions with Disability race categories)
PERSONAL INFORMATION
* First Name: _________________________________________ * Last Name: _________________________________________
*Address: __________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
* City/Town: _______________________________ * State: _______________________________ * Pin Code: _______________________________
* Country: _______________________________ * Nationality: _______________________________ * Gender: o
* Date of Birth: _ _ / _ _ / _ _(dd/mm/yy)
Male / o
Female
* Tel. Number: _____________- _______________________________
(STD Code)
(Landline No./ Mobile No.)
Age as on 14.01.2017: ___________
Email-Address (1)__________________________________________________
(2)____________________________________________________
(Post closure of registrations, individual applicant is required to go online on www.scmm.procamrunning.in and check his/her application status.
Applicant will receive event related information on the email id mentioned above).
Occupation: (tick þ any one)
o Business,
o Self-Employed,
Name of organisation: ______________________
o
Salaried,
Designation: ______________________________
o
Retired,
o
o
Govt. Employee,
Housewife,
o
Student,
o
Sportsperson,
o
Unemployed
Where did you see or hear about our event?: (tick þ any one)
o
Radio,
o
o
Others, if others selected, where _____________________?
Newspaper,
scmm.procamrunning.in
o
Television,
o
Online,
/scmumbaimarathon
o
Outdoor Hoarding,
@runscmm
o
Referred by a friend,
Dream Run, Senior Citizens' Run &
Champions with Disability
* Contact name & number of family/friend/guardian in case of emergencies (such person should not be a participant of the event)
* Name: ____________________________________________________
* Tel. Number: _____________- _______________________________
(STD Code)
(Telephone No. / Mobile No.)
If you wish to send your finish timing via sms on race day to your friends and family, please provide their mobile numbers (max .3 mobile numbers allowed)
1)Mobile Number: _______- __________________ 2)Mobile Number: _______-__________________ 3)Mobile Number: _______-__________________
(Country Code)
(eg: +91)
(Mobile No.)
(Country Code)
(eg: +91)
(Mobile No.)
(Country Code)
(eg: +91)
(Mobile No.)
*Go Green: Do you wish to receive race day information book on email and agree that you will not collect the physical copy from the expo?
Yes
No
*REFUND
In case of entry not accepted, the refund via NEFT will be made in favour of _____________________________________________________________
______________________________(INR 100 will be deducted as processing charges and you will be contacted on your email asking for your NEFT /
Bank account details)
*WAIVER
(must be signed for entry acceptance)
I, __________________________________(full name), declare, confirm and agree as follows that I/my ward..
(I) have given true and complete information in this application form and me/my ward is/am solely responsible for the accuracy of this information; (ii) have fully
understood the risk and responsibility of participating in the Standard Chartered Mumbai Marathon or any event outlined in this application (collectively "the event")
and will be participating entirely at my/his/her risk and responsibility; (iii) understand the risk of participating on a course with vehicular traffic, even if the course
may be regulated/policed; (iv) understand that l/my ward must be of, and must train to, an appropriate level of fitness to participate in such a physically demanding
event and l/my ward have obtained a medical clearance from a registered medical practitioner, allowing me to participate in the event/s; (v) for myself/ourselves
and our legal representatives, waive all claims of whatsoever nature against any and all Sponsors of the event, Mumbai City, all political entities, authorities and
officials, all contractors and construction firms working on or near the course, all Standard Chartered Mumbai Marathon Committee persons, officials and
volunteers, Procam International Private Limited and all other persons and entities associated with the event and the directors, employees, agents and
representatives of all or any of the aforementioned including, but not limited to, any claims that might result from me/my ward participating in the event and whether
on account of illness, injury, death or otherwise; (vi) agree that if I am/my ward is injured or taken ill or otherwise suffer/s any detriment whatsoever, I hereby
irrevocably authorize the event officials and organizers to, at my/our risk and cost, transport me/my ward to a medical facility and/or to administer emergency
medical treatment and l/my ward waive/s all claims that might result from such transport and/or treatment or delay or deficiency therein. I shall pay or reimburse to
you my/my ward's medical and emergency expenses and l/my ward hereby authorize/s you to incur the same; (vii) shall provide to race officials such medical data
relating to me/my ward as they may request. I agree that nothing herein shall oblige the event officials or organizers or any other person to incur any expense or to
provide any transport or treatment; (viii) in case of any illness or injury caused to me or my ward or death suffered by me or my ward due to any medical reasons or
medical condition during the race or at any time thereafter as a result of the event, regardless or not whether such medical reasons or condition shall have been
pre-existing conditions known by me and further regardless of whether I/my ward shall have disclosed, at any point in time, the existence of such reason or
condition to any person, none of the sponsors of the event or any political entity or authorities and officials or any contractor or construction firms working on or near
the course, or any of the Standard Chartered Mumbai Marathon Committee persons, officials or volunteers or Procam International Private Limited or any persons
or entities associated with the event or the directors, employees, agents or representatives of all or any of the aforementioned shall be held liable by me/my ward or
my/my ward's representatives; (ix) in case of any illness or injury caused to me or my ward or death suffered by me or my ward during the event or due to any force
majeure event including but not limited to fire, riots or other civil disturbances, earthquakes, storms, typhoons or any terrorist act, none of the sponsors of the event
or any political entity or authorities and officials or any contractor or construction firms working on or near the course, or any of the Standard Chartered Mumbai
Marathon Committee persons, officials or volunteers or Procam International Private Limited or any persons or entities associated with the event or the directors,
employees, agents or representatives of all or any of the aforementioned shall be held liable by me/my ward or my/my ward's representatives; (x) understand,
agree and irrevocably permit Procam International to share the information given by me/my ward in this application, with all/any entities associated with the
Standard Chartered Mumbai Marathon, at its own discretion; (xi) understand, agree and irrevocably permit Procam International to use my/my ward's photograph
which may be photographed on race day and/or during various functions of the event, for the purpose of promoting Standard Chartered Mumbai Marathon, at its
own discretion; (xii) shall not hold the organizers and all/any of the event sponsors responsible for loss of my/his/her application form and/or application fee in
transit; (xiii) I/my ward do agree to receive information and offers of various brands/products/services as may be sent to me/my ward by the event promoters (or a
person duly authorized by the promoters) on the email address given by me/my ward in this application form; (xiv) I/my ward understand and agree to the event
terms and guidelines.
If applicant is under 18 years of age
as on 14.01.2017
Guardian's Signature
Applicant's Signature
Name & relation of Guardian with Applicant