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 ________________________________