50 States Marathon Club Application

Name______________________________________      Date of birth _______________

Address____________________________________      Sex   M/F      ______

             ______________________________________________

Home phone   ____________________           Other phone ________________

E-mail address _____________________________________________________________

Okay to list Email on web page?   Y/N    _____      Okay to list state of residence?   Y/N _____

Type of membership:  (check only one)

______ Full membership (completed 50 states)    $10                     

______ Standard membership (completed 10 states but fewer than 50)  $10 

$_____ Donation to the club                                                   

$_____ Total of fee and donation       
        

   Upon submission of this application, I agree to assume all risks associated with participation in any activity of the 50 States Marathon Club.  I release all sponsors, officers, board members, employees and any person assisting on a voluntary basis  from any claims of liability resulting from my participation.

Signature_________________________       Date___________________

You may be requested to include a copy of verifiable documentation for each of the races  (i.e. finisher card, race results listing, note from race director, etc.).   Please read the club rules before submitting this application.

Mail application and check payable in US funds to 50 States Marathon Club,  P.O.Box 15638,  Houston,  TX  77220-5638 
If you are from a foreign country, please pay in US cash or by credit card through the online renewal The bank charges $20 to convert foreign checks or money orders to US funds (even if it is payable in US funds).  Checks must come from a US bank.   

Email your name, state, & email address to steveboone@aol.com  so that we will be looking for your application.  As soon as we receive and process your application, we will send you a welcome packet with information about the club.

List of  marathons run in each of ten states (date, finishing time, city/state):

1. _________________________________________________________________________________________

2. _________________________________________________________________________________________

3. _________________________________________________________________________________________

4. _________________________________________________________________________________________

5. _________________________________________________________________________________________

6. _________________________________________________________________________________________

7. _________________________________________________________________________________________

8. _________________________________________________________________________________________

9. _________________________________________________________________________________________

10. _________________________________________________________________________________________

Total completed marathons            _______                        Total Canadian provinces  _______

Total completed ultra marathons     _______                        Total foreign countries      _______

Total career marathons & ultras      _______                        Total continents               _______

Total US states                             _______