Cancer to 5K - Fall 2021 Registration Form
Cancer to 5K is a free 12-week training program designed to introduce or reintroduce cancer survivors to physical activity after diagnosis. More information is available here: cancerto5k.org

Please email us at CT5KRaleigh@gmail.com if you have any questions.
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You may register as a (Cancer) Survivor or a Sherpa (volunteer). Survivors will receive a free entry into the 5K goal race.
Practices begin on Saturday, August 21 at 9am at Pullen Park. Practices will be every Saturday at 9am at Pullen Park in Raleigh and every Tuesday at 6:30pm at Talley Student Union at NC State in Raleigh. The goal race is the Leaves to Leases 5K in Cary on November 13, 2021.
First name: *
Last name: *
Are you registering as a Survivor or a Sherpa (volunteer)? *
Email Address: *
Phone Number: *
Address (Please include Street, City, State, Zip) *
Date of Birth: *
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Gender:
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Shirt Size
If registering as a Survivor: What Type of Cancer were you diagnosed with?
If registering as a Survivor: What is your treatment status?
If registering as a Survivor: Which treatment center did you receive treatment from?
Emergency Contact: First name
Emergency Contact: Last name
Emergency Contact: Relationship to contact
Emergency Contact: Phone number
How did you hear about Cancer to 5K?
Is there any additional information you want to provide?
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