The American Cancer Society: Survey

Thank you for making a commitment to save a life by taking up the fight against cancer!

*1.

Question - Required - First Name

*2.

Question - Required - Last Name

*3.

Question - Required - Email

4.

Question - Not Required - Phone (optional)

5.

Question - Not Required - Event Name: Relay For Life of

*6.

Question - Required - State

*7.

Question - Required - My Pledge
Please make between 1 and 5 selections from the choices below.

	I will raise funds to support American Cancer Society research
	I will educate myself and others about cancer screenings and healthy lifestyle choices
	I will join the American Cancer Society Cancer Action Network (ACS CAN) and help make cancer a legislative priority
	I will support programs and services for local patients battling cancer
	Other

8.

Question - Not Required - If other, please write your pledge here