Survivor & Caregiver Registration Form
Upcoming SlideShare
Loading in...5
×

Like this? Share it with your network

Share
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
894
On Slideshare
894
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
6
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. 2011 Relay For Life of Frisco Event Date: May 20, 2011 Return Registration Form to: Lone Star HS Football Field Kellee Albrecht 14808 Riverside Drive Little Elm, TX 75068 Email: albrechk@friscoisd.org Survivor Registration Come join us for the American Cancer Society’s Relay For Life Celebration for Survivors. If Phone: 469.222.4913 you wish to register for the survivor activities, please complete all the information below Fax: 972.687.7882 and provide your signature twice as described below. Thank you for your interest! or Register online at: Name: ___________________________________________________ www.FriscoRFL.com Address: __________________________________________________ Caregiver Registration City: _________________________ State: ______Zip: _____________ Come join us for the American Cancer Society’s Relay For Life Celebration for Survivors. If you wish to register for the Phone (H): ______________________ (W): ________________ caregiver activities at this event, please complete all the information below and provide your signature agreeing to a Email: _______________________________________________ participant waiver. Thank you for your interest! Cancer Type/Location (optional)_____________________________ Name: _____________________________________ Years survived: ____ Age:______ Address: ___________________________________ Privacy Statement: I understand that by providing my signature and participating in this public event my name, cancer diagnosis, and length of survivorship may be announced; my image and comments may be broadcast in various media formats without compensation; City: _________________ State: _____ Zip: _______ and the American Cancer Society may contact me about other Society programs and events including next year’s Relay For Life. I may notify the American Cancer Society at any time if Phone (H): ______________ (W): _______________ I do not want to be contacted again. Privacy Statement Signature: Email: ______________________________________ ______________________________________ Waiver: In consideration for being permitted to participate in Relay For Life, I hereby for Relationship to Survivor: Family Healthcare provider myself, my heirs, and personal representative assume any and all risks which might be Friend Other associated with the event, and I further waive, release, discharge and covenant not to sue the American Cancer Society, its officers, members, sponsors, organizers or other representatives, or successors and assigns, for any injuries or damages of any kind Name of Cancer Survivor that I am the Caregiver of: whatsoever suffered as a result of taking part in the event and related activities. Participant waiver signature (required): __________________________________________ ______________________________________ Waiver: In consideration for being permitted to participate in Relay For Life, I T-Shirt size (select one): hereby for myself, my heirs, and personal representative assume any and all S M L XL 2XL 3XL Youth: YM YL risks which might be associated with the event, and I further waive, release, My caregiver will be attending Relay with me. discharge and covenant not to sue the American Cancer Society, its officers, members, sponsors, organizers or other representatives, or successors and I am on a Relay Team. Team Name: _______________________________ assigns, for any injuries or damages of any kind whatsoever suffered as a I would like to be involved in Survivor Activities. result of taking part in the event and related activities. I would like to volunteer to help at Relay For Life. I will need assistance getting around the track for the Survivor Lap. ___________________________________________2/16/2011 Participant Waiver Signature (required) I was invited to attend Relay by: _____________________________________ Team Name ________________________________