Survivors Registration

Sunday, September 24, 3pm

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

What type sickle cell disease do you have? *

Please tell us some of your concerns with receiving medical care and support services.

Please tell us where you have received exceptional or above average medical care or supportive services.

Please email me updates

Age *

Gender *

Male

Female

T-Shirt Size *

T-shirts are only guaranteed for individuals who register by Sept. 4. There may or may not be t-shirts available after that date.

I hereby certify I am adequately fit to walk in this activity. In consideration for the acceptance of this entry, I, the undersigned, for myself, my personal representative, beneficiaries, and heirs, knowingly waive, release, and discharge all rights and claims which I have or may have hereafter accrue to me or my estate against the Cure Sickle Cell Foundation, Inc, Jackson State University and/or any other sponsors, organizers and volunteers and assigns for any and all injuries or death suffered by me in this event. I will also allow my picture to be used in publication as a result of this race. *

By checking this box I agree with this statement

*

Survivors Fee