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Spirit of Hope | 5K Event | Free Mammograms | Community Outreach | Community Resources To register for the RABC 5K event, please print this page on your printer. A registration form must be completed for each participant. Complete the entire form and sign the waiver statement. Mail the completed form(s) with check or money order payable to the Race Against Breast Cancer to: RABC, PO Box 4458, Topeka, KS 66604-0458 The Annual Race Against Breast Cancer- October 4, 2008 |
Please Print
Last Name_______________________ First
Name________________Middle Initial__Address_________________________________________City_____________State_____Zip +
4________Age (required)_______
Telephone(______)____________________Email________________________________
Gender: ____Male
_____Female
Category: ____Runner _____Walker ___Volunteer ___
Donation (no entry)
Are you a Breast Cancer Survivor?_______
Please indicate shirt size needed
Child: S__ M__ Adult: S__ M__ L__
XL__ XXL___ (add $1.50)
___ No T-Shirt: I donate the
cost of the shirt to the project
Individual Entry (before Sept. 25) - $20 $ ______________
Family Entry-3 individuals only (before Sept. 25) - $50 $_______________
_____(no.) of Additional Family Members X $7.00 $_______________
Individual Entry (after Sept. 25) - $25 $_______________
Family Entry-3 individuals only (after Sept. 25) - $55 $_______________
Donation (no entry) $_______________
Add $1.50 for each XXL shirt $_______________
Donation for quilt (suggested $2 for 1 ticket or $10 for 6 tickets) $_______________
Donation for dollhouse (suggested $2 for 1 ticket or $10 for 6 tickets) $_______________
Total Amount Due (NO REFUNDS) $_______________
Please complete the following
Waiver Statement (must be signed and submitted with registration)
As an entrant in The Race Against Breast Cancer, I assume complete responsibility for injury to me or damage to property which may occur during the event or while I am on the premises of the event. I hereby release and hold harmless the sponsor, promoters, and all other persons associated with the event from any and all liability for injury or damage, whether caused by negligence of the sponsors, promoters or other persons associated with this event or otherwise. I grant permission for any and all of the foregoing to use any photographs, video tapes, motion pictures, recordings or any other record of this event for any purpose whatsoever. I understand that my rental chip must be returned within seven days of the event or I will be assessed the $30.00 purchase price.
x______________________________________________
____________
Signature (parents signature required if participant is a
minor)
Date
Mail completed form to:
Race Against Breast Cancer,
Inc., PO Box 4458, Topeka, KS 66604-0458
