SURVIVOR CONFIRMATION FORM

Santa Monica Relay For Life

July 24 – July 25, 2004

Santa Monica College- Corsair Field

OPENING CEREMONY— 9:00 am

CANCER SURVIVORS’ OPENING LAP— 9:30 am

Dear Friend:

We invite you to attend the opening ceremonies of the AMERICAN CANCER SOCIETY RELAY FOR LIFE. We encourage you to enjoy the day, make new friends and C E L E B R A T E! RELAY FOR LIFE is an overnight team event that raises awareness of cancer in the community and raises funds to fight cancer. Throughout Relay For Life, teams of friends, neighbors, families and co-workers commit to keeping at least one member walking the track…because cancer never sleeps. As a cancer survivor, you are invited to join other survivors on the inspirational Survivors’ Lap that officially begins our annual RELAY FOR LIFE. For many, the experience of gathering together with other survivors is powerful and moving. Your family is invited to join you during this celebration as well. As a participant in our opening ceremony, you will receive a T-shirt and a special memento. You will also enjoy music and have the opportunity to make new friends. Help us show all RELAY FOR LIFE participants they are making a difference, and that each step brings us closer to the cure.

YES, I am a SURVIVOR and want to participate in the RELAY FOR LIFE!

I will participate in the Cancer Survivors’ Lap.

Name: ____________________________________________________________________

Address: __________________________________________________________________

City: ______________________________________________Zip Code: ___________

Telephone: _____________________________________________________

E-Mail Address: ____________________________________________________________

Years of Survival: _________________________________________________

Type of Cancer: ______________________________________________ (Optional)

Announce my name: Yes or No

T-Shirt size: S M L XL 2XL 3X 4XL Youth S Youth M Youth L

Fax or Mail Form to:

AMERICAN CANCER SOCIETY

Attn: Santa Monica Relay For Life

5731 W. Slauson Ave., Ste. 200

Culver City, CA 90230

Tel: 310.348.0356 Opt. 3/Ext. 246

Fax: 310.348.2328