For More Information
For more information about the Relay For Life, complete and return this form to the RLF Headquarters listed below and you will receive the information you request in just a few days...

We don't currently have electronic form submission capabilities, but you can fill this form out, hit your print button, and then mail it in along with your payment. Look for online forms in the future.

Name:
Company (if applicable):
Address:
Address2:
City: State: Zip:
Daytime Phone:
Fax (if available):
E-Mail:
Yes, I am a cancer survivor and would like to participate in special survivor activities at the Relay For Life!

Yes, contact me about the Relay For Life! I would like to (check all that apply):

  Register a team ($10 per member)
  Join a team that needs more members
  Volunteer to help with the event
  Sponsor the event via my business - call me!
  Make a donation of $_________________
  Other:   


Make checks payable to:
American Cancer Society

Mail completed form to:

Renee Dykes
5404 Broadway
Great Bend, KS 67530

Thank You.

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