Survivor Crop 2008 Registration

About You
First Name:
Last Name:
Address:
 
City:
State:
Zip Code:
Home Phone:  [999-999-9999 format]
Work Phone:  [999-999-9999 format]
Email:
T-shirt Size:
Amount Going to Pay  
Donation Goal  
Payment Options 
 
If you have not used PayPal before, please visit www.paypal.com to make sure this is the option you wish to use. Please Note Registration Fees are Non-Refundable.
Choose your island  (Double click on island to view availability & members)
Only 10 members per team.
 
Information for the Event
Do you want to be identified as a breast cancer survivor?
How did you hear about us?
If Other, please specify:
Emergency Contact
Emergency Phone
Sign Up for $500 Club
Past Participant
2002 2003 2004 2005 2006 2007
Sign up for Altered Can Swap
Sign up for Artist Trading Card Swap
Sandwich Choice

Note: Items in pink require input 

 

If you have any questions or problems with your registration, please contact

Sheila Goldsberry 760-433-9313 or e-mail sjeaux@cox.net



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