Registration for WINS Virtual Cocktail Party: Celebrating 30 years
October 22 at 8 pm EST

1. Registration

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* 1. What is your last name?

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* 2. What is your first name?

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* 3. What are your preferred pronouns?

he/his

she/her

they/their

ze/zir

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* 4. What in the best email addresses to send you information about this event ?

Address 1

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* 5. What is the name of the hospital system/University you are affiliated with ?

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* 6. What is your location ?

US

International