Save Our Sisters

2011 TEAM SOS-NJ REGISTRATION FORM

Name: ____________________________________________ (please print)

Address: ____________________________________________

     ____________________________________________

Home phone: ____________________________________________

Cell phone:  _____________________________________________

Email address: ___________________________________________

Emergency Contact Name and Phone: ______________________________________ 

1^st year            or             Returning team member    (circle one)

How did you hear about Pathways? ___________________________________________

Are you a cancer survivor?   Y     N    If yes, what type of cancer? __________________

• I DO NOT give my permission to have my name or picture used by Pathways and The Connection for Women and Families.
• I DO NOT give my permission to have my contact information distributed to other team members.

As a participant in Dragon Boating, I release The Connection for Women and Families in Summit (and Pathways) from any responsibility of any damage to or loss of property or any liability of injury resulting from my participation. Please check with your doctor to determine the appropriateness of your participation in this activity.

Signature: __________________________________________ Date: _______________

Please return this form to Michele Visco at Pathways, 79 Maple Street, Summit, NJ  07901 before participating in Dragon Boating.

(To Print - "Right-Click & Print")