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Registration Form For Breast Health
Walk ( to be announced )
To register complete form and fax to
941.927.2266 or mail to:
Breast Health Sarasota, Inc.
3663 Bee Ridge Road Sarasota, Fl 34233. For additional
information call
941.927.2226 leave a message if we don't answer.
Name__________________________________________________________________________
Address________________________________________________________________________
City______________________________
State_____________________ Zip________________
Phone: (Day)_________________________________
(Eve.)_____________________________
Age:__________________ Sex: M
F (circle one)
T-Shirt size: M L XL XXL
(circle one only)
 I'm
planning to walk and here is my registration fee of 10$
 How
did you hear about the Breast Health
Walk?___________________________________________I
am not able to participate in the Breast Walk but would like to make
a donation.
Enclosed
is my check for...$100_____ $50_____ $25_____ $____
Visa___ MC___ AM____ EX___ Diners___ Acct#______________________Ex Date:__________________ I
am walking on behalf of someone who has/had Breast Cancer or a
related disorder. List Relationship...
____________________________________________________________________________________
I
would like to volunteer for Breast Health Walk and/or other
activities________
(please check if interested)My
company has a matching gift program. Name/address of
company______________________________
Disclaimer
I hereby waive all claims against Breast
Health Sarasota Inc., for any personal injury that I might suffer in
this event. I attest that I am physically fit and prepared for this
event. I grant full permission for organizers to use photographs of
me and quotations from me in legitimate accounts and promotions of
this event.
Signature X___________________________________
Signature
X________________________________________ (parent or guardian's
signature if less than 18 years of age)
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