Registration Form 2012

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					                                      APPLICATION FORM
             Breast Cancer Action Nova Scotia’s S.E.A.R.C.H Retreat
                            October 19 – 21, 2012
           For women in Cape Breton who have been diagnosed with breast cancer

                              $75 per person for the entire weekend!
                                  Space is limited to 40 women.

Date: ___________________________ Registration Deadline: October 1, 2012 |Selection
Notification: October 6, 2013

Name: _____________________________________________________________________________

Address:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Email: _______________________________________________________________________________

Phone (Home): ___________________ Phone (Cell): ___________________

Emergency Contact: _____________________ Phone Number: _______________________

Year of Diagnosis: ______

Dietary Restrictions:
_____________________________________________________________________________________

Physical Restrictions:
_____________________________________________________________________________________
_____________________________________________________________________________________

How did you hear about the retreat: _______________________________________________________

Payment Method:

□ Credit Card
□ Check (can be made out to Breast Cancer Action Nova Scotia)
□ By Phone (902-465-2685)

Credit Card Information: □ Visa □ Master Card
Card #: _______________________________ Exp Date: ___ /___ Verification Code (3 digits): ______
Name on card (print clearly): ____________________________________________________________

           Breast Cancer Action Nova Scotia | Phone: (902) 465-2685 | Fax: (902) 484-6436
         barbarathompson@bcans.ca | 967 Bedford Highway, Suite 205 | Bedford, NS B4A 1A9
   All payments must be received by October 12th in order to reserve your place.




  Breast Cancer Action Nova Scotia | Phone: (902) 465-2685 | Fax: (902) 484-6436
barbarathompson@bcans.ca | 967 Bedford Highway, Suite 205 | Bedford, NS B4A 1A9

				
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posted:10/4/2012
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