Strides for Survival Breast Cancer Awareness Walk Registration
Join us for the Breast Cancer Awareness Walk hosted by Black Health Professions Student Organization as we come together to raise awareness and funds for breast cancer research. Your participation will help support vital programs and make a difference in the fight against breast cancer. Please fill out the form below to register for the event. Whether you walk individually or as part of a team, your contribution matters!
Name
*
Mr.
Mrs.
Miss.
Dr.
Prefix
First Name
Last Name
Suffix
Are you a Current UCCS Student?
*
Yes
No
Student ID
*
Enter N/A if not a current Student
Are you UCCS Faculty or Staff?
*
Yes
No
UCCS Email
*
example@example.com
If you're not a Student, Faculty/Staff, please enter your email below
*
Number
*
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Emergency Contact Information
Name
*
First Name
Last Name
Email address
*
example@example.com
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to you
*
Medical Information
Are there any medical conditions, limitations, or allergies we should to be aware of?
*
Yes
No
If Yes, write them below.
*
Write N/A if answered "No"
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Release and Waiver of Liability
INITIAL
*
e.g. if my name is John Doe, Initial will be JD
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Next
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My Products
*
prev
next
( X )
Student
$
5.00
Quantity
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9
10
Faculty/Staff
$
7.00
Quantity
1
2
3
4
5
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8
9
10
Public
$
10.00
Quantity
1
2
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10
Submit
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