Worship in Pink Weekend

Registration Form

Thank you for registering for our 5th Annual Worship in Pink Weekend, October 22nd, 23rd, and 24th! Please complete the registration form in its entirety. For questions, email worshipinpink2010@gmail.com or call 404-459-8700. The registration deadline is October 1, 2010.

• Name of Religious Organization
• Address of Organization
  Street Address
  Address Line 2
  City
  State
  Postal / Zip Code
• County
• Telephone - (###) - ### ####
• Web Site
• WIP Weekend Coordinator Name
• Role in Organization (if applicable)
• Address Where Registration Material Should Be Mailed
  Street Address
  Address Line 2
  City
  State
  Postal / Zip Code
• Telephone - (###) - ### ####
• Email
• Preferred Pick-Up Location: Buckhead/Sandy Springs
  Greater Atlanta Affiliate of Susan G. Komen for the Cure
  4840 Roswell Road
  Atlanta, GA 30342 Clayton County
  Southern Regional Medical Center
  11 SW Upper Riverdale Road
  Riverdale, GA 30274 Henry County
  7823 Spivey Station Blvd.
  Suite 100
  Jonesboro, GA 30236 Cobb County - Acworth
  Cobb/Douglas Public Health
  4489 Acworth Industrial Drive
  Acworth, GA 30101 Cobb County - Marietta
  1650 County Services Parkway
  Marietta, GA 30008 North Fulton County
  TurningPoint Women's Healthcare
  11180 State Bridge Road
  Suite 506
  Alpharetta, GA 30022 South Fulton County
  West End Medical Center
  868 York Ave., SW
  Atlanta, GA 30310
• Number of Members in Organization
• Number of Packets Requested (maximum of 1000)
• Ethnic Breakdown of Recipients of Packets by Percentage::
• African-American
• Asian/Pacific Islander
• Hispanic/Latina
• Caucasian
• Other
• If Other, please specify
• Planned Activity (check all that apply): 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 On-site breast cancer screening Other
• If Other, please list