2024 Webinar 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.

If you require reasonable accommodations to attend this event, kindly email us at cancerandcareers@cew.org with the subject line "Reasonable  Accommodation Request."

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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 (If you plan on dialing-in to access sound, please specify the phone number you will be calling from.)

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* 5. Mailing Address

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* 6. City

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* 7. State/Territory (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. Country:

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* 10. Company/Organization (If applicable)

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* 11. Title (If applicable)

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* 12. Age

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

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* 14. Treatment Status (If applicable)

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

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* 16. Which of the following best describes you?

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* 17. Are you transgender?

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* 18. What are your pronouns?

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* 19. Are you Hispanic, Latine, or Spanish descent? 

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

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* 21. Do you / the patients you serve speak any language besides English fluently?

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* 22. If you answered "Yes" above:

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

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* 24. Employment status:

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* 25. Please select all 2024 sessions you would like to register for

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* 26. Are you planning to request free continuing education credits (CEs/PDCs) or a general certificate of participation?

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