Registration Form

Please complete the following questions and we will confirm your registration. 

What is your first name? 

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* 1. What is your first name? 

What is your last name? 

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* 2. What is your last name? 

What is your full mailing address (street, city, state, zip)

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* 3. What is your full mailing address (street, city, state, zip)

What is your phone number? 

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* 4. What is your phone number? 

What is your personal email address? 

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* 5. What is your personal email address? 

What year did you turn 18 years old (this will assist the facilitator in customizing music)?

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* 6. What year did you turn 18 years old (this will assist the facilitator in customizing music)?

Do you have any dietary restrictions?

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* 7. Do you have any dietary restrictions?

For cancer survivors: This workshop is two days long and we require full participation both days. Due to the stamina and focus required to participate, we recommend that you only register if you completed your treatment at least three months prior to the start of the workshop (April 14).

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* 8. For cancer survivors: This workshop is two days long and we require full participation both days. Due to the stamina and focus required to participate, we recommend that you only register if you completed your treatment at least three months prior to the start of the workshop (April 14).

For Hospital Staff/Community Support Person:

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* 9. For Hospital Staff/Community Support Person:

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