Mile of Champions Application

Mount Desert Island Marathon

PO Box 1032

Northeast Harbor, Maine 04662

(Please print clearly. One application per stone.)

Name: __________________________________________________________________________________________________________

Address: ________________________________________________________________________________________________________

State: ________________ Zip:_______________ Country: ________________________

Email: ________________________________________ Phone: _____________________

MILE OF CHAMPIONS ENROLLMENT

Please accept my application to adopt/sponsor a stone along the Mile of Champions. Enclosed is my check or credit card information for $100. per stone. These funds will help support The Neighborhood House.

Please name my stone(s) in honor of (athlete, friend, business, etc): ___________________________________________

Method of payment submitted. Please make checks payable to MDI Marathon, please write MOC (Mile of Champions) in memo:

Check:______ MC:______ VISA:______

Account number: _____________________________________________________________Expiration Date: _____________

3 digit card ID#: __________ (found on back of card) Name on card: _____________________________________________

Cardholder signature: ______________________________________________________

You will be sent a certificate and listed in our race program indicating that the name above has been inducted into the Mile of Champions.

Signature: _____________________________________________________________________________

Date: ___________________

The Mount Desert Island Marathon reserves the right to accept and reject any applications.