2023 Virtual Midwest Conference Registration Form

Cancer and Careers respects and protects the privacy of all visitors and users of our services. Cancer and Careers is the sole owner of any information collected through its programs. All information submitted will only be viewed by the Cancer and Careers staff and no identifying information will be shared publicly.

We strive to create programs and services that represent and serve the full diversity of the cancer community. We are asking the following demographic questions to ensure that we are meeting this goal.

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* 1. First Name

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* 2. Last Name

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* 3. Email Address

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* 4. Phone Number

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* 5. Mailing Address

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* 6. City

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* 7. State (if outside the United States, please select "Other" at the bottom of the dropdown menu and type in state/province and country)

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* 8. Zip Code

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* 9. Company/Organization (if applicable)

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* 10. Title (if applicable)

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* 11. Age (or average age of patients you serve)

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* 12. Which of the following categories, if any, apply to you?: (Please check all that apply.)

Patient/Survivor

Healthcare professional (nurse, social worker, navigator, doctor, etc.)

Nonprofit professional

Caregiver

Friend/Family member

HR professional

Manager

Coworker

None of the above/Other (please specify)

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* 13. Treatment Status:

Just diagnosed, pre-treatment

In-treatment (1 year or less)

In-treatment (1 year - 3 years)

In-treatment (3 years - 5 years)

In-treatment (5 years or more)

Post-treatment (5 years or less)

Post-treatment (5 years or more)

Not diagnosed

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* 14. Cancer Type (If you have never been diagnosed, please type "N/A.")

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* 15. Which of the following best describes you?

Woman

Man

Non-binary

Agender

Gender Fluid

I don't know / I am not sure

Prefer not to answer

Prefer to self-describe (please specify)

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* 16. Are you transgender?

Yes

Prefer not to answer

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* 17. What are your pronouns?

She/Her

He/Him

They/Them

Ze/Zir

Ze/Hir

Prefer not to answer

Prefer to self-describe

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* 18. Which of the following best represents your race/ethnicity? Please select all that apply.

Asian or Asian American

Black or African American

Hispanic, Latinx, or Spanish origin

Native American or Alaska Native

Native Hawaiian or other Pacific Islander

Non-Hispanic White

Don't know

Prefer not to answer

Prefer to self-describe

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* 19. Do you / the patients you serve speak any language besides English flutently?

Yes, I speak one or more other language(s) fluently

Yes, the population I work with speaks one or more other language(s) fluently

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* 20. If you answered Yes to the above:

I speak the following language(s) fluently

The population I work with speaks the following language(s) fluently

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* 21. Have you ever served in the U.S. military or the military reserves?

Yes

Prefer not to answer

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* 22. Please choose the option(s) that best reflect your ability status. We are interested in this identification regardless of whether you typically request accommodations. (Please select all that apply.)

I describe myself as a person:

With vision loss/low vision or who is blind

Who is hard of hearing or deaf

Who uses a wheelchair, crutch, or other assistive mobility device

With a brain injury or other acquired cognitive disability

A disability not listed above

I do not identify with a disability

Prefer not to answer

Prefer to self describe:

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* 23. Employment Status

Employed full-time

Employed part-time

Self-employed

Employed full-time but looking for a new job

Employed part-time but looking for a new job

Unemployed, looking for full-time work

Unemployed, looking for part-time work

Neither employed nor looking for work

Retired

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* 1. First Name

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* 2. Last Name

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* 3. Email Address

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* 4. Phone Number

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* 5. Mailing Address

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* 6. City

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* 7. State (if outside the United States, please select "Other" at the bottom of the dropdown menu and type in state/province and country)

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* 8. Zip Code

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* 9. Company/Organization (if applicable)

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* 10. Title (if applicable)

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* 11. Age (or average age of patients you serve)

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* 12. Which of the following categories, if any, apply to you?: (Please check all that apply.)

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* 13. Treatment Status:

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* 14. Cancer Type (If you have never been diagnosed, please type "N/A.")

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* 15. Which of the following best describes you?

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* 16. Are you transgender?

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* 17. What are your pronouns?

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* 18. Which of the following best represents your race/ethnicity? Please select all that apply.

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* 19. Do you / the patients you serve speak any language besides English flutently?

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* 20. If you answered Yes to the above:

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* 21. Have you ever served in the U.S. military or the military reserves?

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* 22. Please choose the option(s) that best reflect your ability status. We are interested in this identification regardless of whether you typically request accommodations. (Please select all that apply.)I describe myself as a person:

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* 23. Employment Status

* 22. Please choose the option(s) that best reflect your ability status. We are interested in this identification regardless of whether you typically request accommodations. (Please select all that apply.)

I describe myself as a person: