2011 Chicago Cancer Rights Conference - Registration Form

2011 Chicago Cancer Rights Conference Registration Form

*REGISTRATION FOR THE CHICAGO CANCER RIGHTS CONFERENCE IS NOW FULL. Those registering after 4:45 PM PST on Friday, June 17th will be added to a waitlist.

Any registration openings that become available will be granted at the conference on a first-come-first-serve basis. For more information, please contact Angelica Corral, CLRC Communications Coordinator at Angelica.Corral@lls.edu or 213-252-8449. Thank you!

Please complete the following conference registration form.

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First Name (Required.)

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Last Name (Required.)

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Organization

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Title

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Address (Required.)

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City (Required.)

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State (Required.)

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Zip Code (Required.)

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Phone Number xxx-xxx-xxxx (Required.)

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Alternate Phone Number xxx-xxx-xxxx

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Email Address

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Note: Any statistical information provided (Ethnicity, Gender, Age, etc.) will be kept anonymous and will only be used for research purposes in a group format. The CLRC uses this information to write grants for the continued funding of our organization and will allow us to continue to provide free services, such as the Cancer Rights Conferences.
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Are you a:

Patient

Survivor

Caregiver

Advocate

Healthcare Professional

Attorney

Other

Question Title

If you have been diagnosed with cancer, what type of cancer?

Bone

Brain

Breast

Colon

Carcinoma

Cervical

Esophageal

Hodgkin

Kidney

Laryngeal

Leukemia

Liver

Lung

Lymphoma

Melanoma

Mouth

Multiple Myeloma

Ovarian

Pancreatic

Prostate

Rectal

Sarcoma

Skin

Stomach

Testicular

Throat

Thyroid

Uterine

Other (please specify)

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Ethnicity

Caucasian

Hispanic

African American

Asian

Pacific Islander

Other

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Gender

Male

Female

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Age

0-18

19-40

41-64

65+

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Do you need Spanish translation?

Yes

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Do you need accommodations (dietary restrictions, physical access, etc.)?

Yes

If yes, please explain here

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How did you hear about this conference?

CLRC Flyer

CLRC Website

Email from the CLRC

Friend

Family Member

Co-Worker

Health Care Professional

Another Cancer Organization

Other (please specify)

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What is one thing you hope to learn or take away from this conference?

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Do you wish to receive the CLRC's monthly e-newsletter?

Yes

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* First Name (Required.)

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* Last Name (Required.)

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* Organization

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* Title

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* Address (Required.)

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* City (Required.)

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* State (Required.)

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* Zip Code (Required.)

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* Phone Number xxx-xxx-xxxx (Required.)

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* Alternate Phone Number xxx-xxx-xxxx

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* Email Address

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* If you have been diagnosed with cancer, what type of cancer?

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* Ethnicity

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* Gender

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* Age

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* Do you need Spanish translation?

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* Do you need accommodations (dietary restrictions, physical access, etc.)?

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* How did you hear about this conference?

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* What is one thing you hope to learn or take away from this conference?

Question Title

* Do you wish to receive the CLRC's monthly e-newsletter?

First Name (Required.)

Last Name (Required.)

Organization

Title

Address (Required.)

City (Required.)

State (Required.)

Zip Code (Required.)

Phone Number xxx-xxx-xxxx (Required.)

Alternate Phone Number xxx-xxx-xxxx

Email Address

If you have been diagnosed with cancer, what type of cancer?

Ethnicity

Gender

Age

Do you need Spanish translation?

Do you need accommodations (dietary restrictions, physical access, etc.)?

How did you hear about this conference?

What is one thing you hope to learn or take away from this conference?

Do you wish to receive the CLRC's monthly e-newsletter?