Registration Form 8.16.indd - Mahaska Health Partnership

Breast Cancer Awareness Walk
FriDAy
OctOBER 7
Noon - 1:00 pm
on the Square in Oskaloosa, $25. registration due
by Sept. 22. (in case of bad weather: Penn Central Mall)
Funds raised assist with breast cancer education and mammograms for women with a financial need.
Free Women’s Breast Health Night
Tuesday
OctOBER 25
6:30 - 8:00 pm
Gateway Church of the Nazarene. This year’s program
will feature General Surgeon Timothy Breon, MD, FACS.
Pre-registration required online
or call 641.672.3369.
Registration
DUE SeptEMBER 22
Register online at mahaskahealth.org or mail the form below to:
MHP Cancer Care and Infusion Center | 1229 C Ave. E., Oskaloosa, IA 52577
Make checks payable to: Mahaska Health Partnership
Name:_________________________________________________
I plan to attend
(check all that apply):
Phone:_________________________________________________
Email:__________________________________________________
Adult T-shirt size:
o S o M o L o XL o 2XL o 3XL o 4XL o 5XL
Shirts will be available for pick-up Noon - 5:00 pm on October 6 or will be brought
to the walk. Shirts may be picked up at entrance #1 on the MHP campus.
o
Breast Cancer Awareness Walk
o
Free Women’s Health Night
Friday, Oct. 7 (Sept. 22 deadline)
Tuesday, Oct. 25
I assume all risk associated with this event including and not limited to falls, injuries, contact with other participants, effects of weather, traffic
and sidewalk conditions. I, for myself and anyone entitled to act on my behalf, waive and release Mahaska Health Partnership and the City of
Oskaloosa from all claims and liabilities. I grant all permission and all forgoing to use any and all motion pictures, video and/or photographs for
any legitimate reason.
Signature:_________________________________________________________________________
A parent or guardian must sign for individuals under the age of 18.
Date:_____________________________