Registration Form

March for the Cure
Assisting women in the fight against breast cancer!

Registration Form

Mount Auburn March for the Cure
Onlline Registration ends October 10, 2010
c/o Kim King Smith Events              or      c/o Southwestern High School FFA
5429 West 900 South                                 Attn: Mrs. Pam Meyer
Edinburgh, IN 46124                                  3406 West 600 South
317.512.0172                                            Shelbyville, IN 46176
317.729.2421                                                      317.729.5122

If you would like to register and pay online, please complete the registration form below. In the comment box, please submit your name, the date you paid, and the registration amount. Finish by pressing "Buy Now" to pay through PayPal.

Also, you may register online and pay by check. Please complete the registration form below and in the comment box submit your name, where you are sending the check, the date you registered, and the registration amountFinish by pressing "Submit" and send a $15 check made out to The Little Red Door M.A.P. and send to the address you submitted in the comment box. DO NOT SELECT THE 'BUY NOW' BUTTON IF PAYING BY CHECK.

If you have any questions about completing this form, please feel free to call Kim King Smith at 317.512.0172.

First Name(required):
Last Name(required):
Address(required):
City(required):
Zip Code(required):	(5 digits)
State(required):
Birthdate(required):
Gender:
Daytime Phone(required):
Cell Phone(required):
Email(required):
Cancer Survivor/In Treatment:

Volunteer prior/day of event

Participant Signature(required):
Parent/Guardian Signature (Absolutely Required if participant is under 18 years):
Questions/Comments:	Enter comments here!

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