Team Commitment Fee

$150.00

3rd Annual Santa Monica

Relay For Life

July 24 & 25, 2004

Santa Monica College - Corsair Field

To register your team, please complete & return with $150 to American Cancer Society

Attn: L. LaShawndra Pace – Santa Monica Relay For Life

5731 West Slauson Avenue, #200, Culver City, CA 90230

Phone: 310 348-0356, Option 3/Ext. 246 Fax: 310.348.2328

Please type or print

New Team? _______ New Team Captain?_________ New Co-Captain?_________

TEAM NAME:___________________________________________________________

COMPANY/AFFILIATION:_________________________________________________

SPONSOR? Presenting:____ Platinum:____ Gold:____ Silver:____ Bronze:_____

TEAM CAPTAIN: ________________________________________________________

ADDRESS:______________________________________________________________ ______________________________________________________________

HOME PHONE:_______________________ WORK PHONE:_____________________

EMAIL:________________________________________________________________

TEAM CO-CAPTAIN: ____________________________________________________

COMPANY:_____________________________________________________________

ADDRESS:_____________________________________________________________ _____________________________________________________________

HOME PHONE:_______________________ WORK PHONE:_____________________

EMAIL:________________________________________________________________

FORM OF PAYMENT: check [ ] cash [ ] Sponsor [ ] credit card [ ] Paid $150_______

Type of Card:______ Credit Card #:_____________________________ Exp. Date:_______ SIGNATURE:_____________________________________

For office use only:

Date fee received:__________ Received by:_____________ Seibel:___________ Team #:_______