C5 Registration Form Question Title 1. What is your first name? Question Title 2. What is your last name? Question Title 3. At what email address would you like to be contacted? Question Title 4. Are you a C5 member? Yes No Question Title 5. Do you have any dietary restrictions? No dietary restrictions Vegan Kosher Other (please specify) Question Title 6. You may be photographed and/or videotaped at C5 events/activities. Registering indicates consent to be photographed and/or videotaped for use on C5 website and/or social media sites. If you DO NOT want your image used, please check the box below. Yes, you may use my image No, please do not use my image Question Title 7. Would you like to receive the C5 News and Updates newsletter? Yes No I am already subscribed! Question Title 8. Please select the primary location where you spend majority of your work time: Brooklyn Bronx Manhattan Staten Island Queens NY State (outside NYC) Other (please specify) Question Title 9. Please select your primary job function: Health care provider Research Academic teaching/education Management/administration Patient navigation Other (please specify) Question Title 10. Please enter the title for your primary job function: Next
