Worship in Pink Weekend Registration Form

Thank you for registering for the 7th annual Komen Atlanta Worship in Pink weekend, October 19th, 20th and 21st! Please complete the registration form in its entirety. For questions, email lmurphy@komenatlanta.org or call 404-459-8700.

(*) - Required
Name of religious organization (*)
Address of organization
City
State
Zip
Phone (*)
County	Choose one... Cherokee Clayton Cobb Coweta DeKalb Douglas Fayette Forsyth Fulton Gwinnett Henry Newton Rockdale Other
Web site
WIP weekend coordinator name (*)
Role in Organization (if applicable)
Coordinator email(*)
Will this be the organization's first time participating in WIP? (choose) Yes No
Pick-Up Location: Komen Atlanta Office 4840 Roswell Road Building D, Suite 100 Atlanta, GA 30342
Number of members in organization
Number of Packets Requested: (1,000 maximum)
Ethnic breakdown of packet recipients by percentages Information can be provided in many different languages - please contact the Komen Atlanta office for more information. African-American Hispanic/Latino Caucasian Asian/Pacific Islander Other (please specify):