Mt. Nebo Breast Cancer Event

In Memory of Billie Jean "BJ" Jackson

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9th Annual Event

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Registration Form

Please use the electronic form below to register online.
If you wish to send in your registration via paper-mail, please download and print the PDF document using the download link below.

Payment Info:
Once you process this electronic form, you’ll be given the opportunity to send in your electronic payment via PayPal on the next page.
If you are using the paper form, please send a check or money order in the envelope with your registration.

Thank you!

PDF Registration Form – Download

Registration form(s):

Mail to: Mt. Nebo Missionary Baptist Church, Post Office Box 1989, Pine Bluff, AR 71613

Scan and email to: mtnebobreastcancerbj@yahoo.com

*Payment/Donation Options*

Make your check or money order payable to: Mt. Nebo

CashApp: $mtnebobcbj14

PayPal: paypal.me/mtnebobreastcancerbj

In the “add a note” section, please list the individual name(s), contact number, t-shirt size(s), and quantity.

When donating via PayPal, use the “Send as Friends & Family” option rather than Products and Services

T-Shirts

Must be ordered by: October 8th, 2023

Available Sizes: YXS – 5XL
Price: $30 ea

Name *

First

Last

Mailing Address *

City *

State *

Zipcode *

Home/Cell Phone *

Email Address *

Date of Birth *

Age on Race Day *

Gender *

Male
Female

T-Shirt Sizes

If you would like a t-shirt mailed, send $6.00 for postage, registration form & include your mail-to address.

Type of Entry *

Individual/Adult
Individual/Youth

Breast Cancer Survivor? (Would you like to be recognized as a breast cancer survivor?) *

Yes, I am a survivor
No

If you're a survivor, how many years?

Donation

Please use my full donation to continue the mission and find the cure!

Entry Fees-Walk/Run (Includes T-Shirt)

Additional Tax-Deductible Donation

Total Amount Enclosed? *

SIGNATURE WAIVER (MUST BE SIGNED) *

In consideration of your accepting this entry, I, the below signed, intending to be legally bound, for myself, heirs, my executors and administrators, waive and release all rights and claims for damages I may have against the race, and sponsors and their representatives, successors for any and all injuries suffered by me in said event. I attest that I will participate in this event as a run/walk, and that I am physically fit and sufficiently trained for the completion of this event.

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

9th Annual Event Schedule

Saturday, October 28, 2023
9:00 am
Saracen Landing Pavilion
200 Lake Saracen Dr.
Pine Bluff, AR