Race Date: Saturday, October 15, 2011 * 8 a.m.

Deadline to join team is September 30.
Donations are accepted through October 15.

First Name:	Middle Initial:
Last Name:
Address:
City:
State:
Zip Code:
Phone:
Mobile Phone:
E-mail:	*Required
Age:
Gender:	Male Female
T-shirt Size:	S M L XL 2XL

Please register me for the following:

5K Run (timed)
5K Walk
1 Mile Fun Walk
Sleep in for the Cure (designate donation amount below)

I am a breast cancer survivor. (By checking this box, you are indicating to the Komen Race for the Cure your wish to be recognized as a survivor and to receive a complimentary pink t-shirt and cap.

Payment Options:

By submitting this form, I give KASA permission to register me for the Susan G.Komen Race for the Cure or Sleep in for the Cure on October 15, 2011 in Lexington. KASA will process the registration through the Susan G. Komen Lexington Affiliate and invoice me the amount specified below.

Sleep in for the Cure. Desinate donation amount here:

Run/Walk (no chip timing) $25 Run/Walk (chip timed) $30

Note: A KASA staff member will pick up your t-shirt from the Komen headquarters in Lexington. It will be available to you the day of the race, or you may request it be mailed to you by calling (800) 928-KASA.

Payment Method

Please choose one of the following:

Please invoice me using address above
Check (Make check payable to KASA for the Cure. Mail a copy of this form and check to KASA for the Cure, 152 Consumer Lane, Frankfort, KY 40601)
Credit Card (please call the KASA office at (800) 928-KASA with credit card information)

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Wayne Young, Executive Director, General Counsel
Rhonda Caldwell, Deputy Director
Clyde Caudill, Legislative Liaison
Wanda Darland, Web, Publications, & Affiliate Services Coordinator
Shirley LaFavers, Director of Professional Development

152 Consumer Lane
Frankfort, KY 40601
(800) 928-KASA or
(502) 875-3411

Fax (502) 875-4634