Pink Sunday Online Registration Form

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Pink Sunday

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Pink Sunday Online Registration Form

Please fill out the required fields and click "Submit," if you would like a paper registration as well, please click here and send it in.

If you would like to participate but are unable to host Pink Sunday on Sunday, October 9th, please complete the registration form and indicate a date that your church (or group) would be willing to host the program (after Oct. 9). We encourage all faiths to participate, as well as clubs, groups and organizations that wish to educate their members on the importance of early detection.

*1.

Question - Required - Name of Religious Organization

(Maximum response 255 chars, approx. 5 rows of text)

*2.

Question - Required - Address of Organization

(Maximum response 255 chars, approx. 5 rows of text)

*3.

Question - Required - Telephone Number

*4.

Question - Required - Pink Sunday Ambassador Name

Question - Not Required - Role in Organization (if applicable)

*6.

Question - Required - Email address

*7.

Question - Required - Best Way to Contact

	Email
	Telphone

Question - Not Required - Estimate of members in Organization

*9.

Question - Required - Ethnicities in your Organization
Please make between 1 and 5 selections from the choices below.

	African-American
	Hispanic/Latina
	Asian/Pacific Islander
	Caucasion
	Other (Please Specify Below)

10.

Question - Not Required - If "Other," please describe

*11.

Question - Required - Planned Activity (Check All That Apply)
Please make between 1 and 8 selections from the choices below.

	Guest Speaker
	Special tribute to survivors and co-survivors
	Special tribute to those who have lost their lives to breast cancer
	Education table
	Pink treats, i.e. pink cupcakes, punch, flowers, ribbons
	Members will wear Pink
	Bulletin board featuring educational material and other information
	Other (Please describe below)

12.

Question - Not Required - If "Other," please describe here

13.

Question - Not Required - Pink Sunday will be held October 9, 2011, however if your place of worship chooses to hold their events on an alternate date, please state the date and reason.

Greater Amarillo Affiliate of Susan G. Komen for the Cure©
P.O. Box 50610 Amarillo, Texas 79159 · Phone: 806-354-9706 · Email: director@komenamarillo.org

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