Breast Cancer Awareness Walk | Registration

Please fill out the form below to register for the Cancer Walk or to purchase a t-shirt.

If you prefer, you can download the registration form here.

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Age

As a Cancer survivor, I would like to participate in the Survivor Celebration held before walk begins:

Choose One: *

Participant w/ T Shirt – $20.00
Cancer Survivor – $0.00
T Shirt Only – $20.00
T Shirt Only – Adult 2XL, 3XL, 4XL – $25.00

Cancer survivors receive a free t-shirt.

Shirt Size *

– As a participant in the “Savoy Breast Cancer Awareness Walk 1 mile fun run/walk, I, for myself, my executor, administrators, and assigns, do hereby release and discharge Savoy Indigent Patient Support, Savoy Cancer Center, the town of Mamou, the event site, their management, their officers, members, sponsors, organizers, or their representatives, or their successors, and all cooperating businesses and organizations from all claims of damages, demands, actions, and causes whatsoever, in any manner arising or growing out of my participation or that of my child in this event.
– I give my full permission for the use of my name and photograph in this event. I also give my full permission for such first aid as is deemed necessary to be provided to me or my child on the premises or prior to transport to a hospital for further treatment.

Click here to agree to the waiver. *

I agree.

Total Amount

$0.00

PayPal Commerce *

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Card Holder Name