RAC Registration form - Cancer Institute(WIA)

Race Against Cancer
Cancer Institute’s Diamond Jubilee Run
Sunday, 3rd August, 2014 at Island Grounds, Chennai
Registration Form
Name:
Date of Birth:
Address:
Email id:
Phone no.
Category:
Gender: Female
Male

3rd Gender
Distance: 2km
4km

8km
Blood Group:




Nationality:
CI Staff/Student 
CI Survivor 
CI Alumni 
School student 
College student 
Identity proof: CI staff Id Pan Card  Driving License 
General 
Voter Id 
CI UHID 
Identity proof number: ____________________________________
Emergency contact person:
Emergency contact number:
Are you a cancer survivor? Yes 
No 
Family of survivor  Friend of survivor 
Do you have any medical illness (please tick as applicable)?
Cardiac problems  Diabetes 
Hypertension 
Any other:_____________
What is the longest distance you have run (please mention in kms)? _____________
Do you consume alcohol?
Never 
In the past 
Occasionally 
Regularly 
Do you consume tobacco? Never 
In the past 
Occasionally 
Regularly 
T-shirt size:
Medium 
Large
XL
Small 
Completed registration forms can be sent to The Director, Cancer Institute (WIA), No.38, Sardar
Patel Road, Adyar, Chennai – 36. Cash payments can be made at the above address. Cheques to
be drawn in favour of ‘Cancer Institute (WIA)’.
Last date for registration is 28th July 2014. To register online go to cirac.doattend.com

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