Author: ACS User

SURVIVOR and CAREGIVER REGISTRATION
Relay For Life of Charlotte
Visit www.relayforlife.org/charlottenc to register online

___I am a Survivor ___I am a Caregiver ___I am both
Name___________________________________________________________________________________________
Address_________________________________________________________________________________________
City_________________________ State___________ Zip___________________________________________
Phone____________________________________ Email_________________________________________________
T-Shirt Size: YS___ YM___ YL___ S___ M___ L___ XL ___ XXL___ XXXL___

Survivor and Caregiver Dinner
____ YES! I would like to attend the Survivor and Caregiver Dinner.
____ YES! I would like to attend the Survivor and Caregiver Dinner and bring 1 person with me.

Relay For Life Opening Ceremony, Survivor and Caregiver Lap
____ YES! I am going to attend the Relay for Life Opening Ceremony and stay for the activities.

VOLUNTEER OPPORTUNITIES:
Please check the following if you would like to be contacted about volunteering

OPTIONAL: Gender: _____ Male _____ Female Date of Birth ____/____/_____

Relay For Life:
__ Form a team
__ Relay planning committee
__ Become a corporate sponsor

Patient Service Programs:
__ Reach to Recovery Program
__ Road to Recovery Program
__ Look Good… Feel Better

Advocacy:
__ Become a member of ACS
Cancer Action Network (ACS CAN)

Optional Information : (Please check only if you would like to be contacted)
I'm interested in becoming involved in other ACS volunteer opportunities: ____ Yes
I'm interested in including ACS in my Will, Trust, or Estate Plan: ____ Yes
I'm interested in advocating for Legislation to help cancer patients and their families: ____ Yes
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Please return completed registration form to any Team Captain or mail to:
Relay For Life of Charlotte
Attn: Survivor and Caregiver Committee
1901 Brunswick Avenue, Ste. 100, Charlotte, NC 28207