Krusenberg 2018:

MPNEhubs
22nd- 25th November 2018
Krusenberg Herrgård

Application

Workshop participation upon application only, please do not book your travel before you have been accepted.

DEADLINE FOR APPLICATION
15th October 2018

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* 1. Your contact information

First Name

Family Name

Address

City/Town

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

* 2. Your relationship to Melanoma

	Stage 1	Stage 2	Stage 3	Stage 4	currently NED (no evidence of disease)	n/a
I am a Melanoma patient	I am a Melanoma patient Stage 1	I am a Melanoma patient Stage 2	I am a Melanoma patient Stage 3	I am a Melanoma patient Stage 4	I am a Melanoma patient currently NED (no evidence of disease)	I am a Melanoma patient n/a
I am the carer of a Melanoma patient whose disease is in	I am the carer of a Melanoma patient whose disease is in Stage 1	I am the carer of a Melanoma patient whose disease is in Stage 2	I am the carer of a Melanoma patient whose disease is in Stage 3	I am the carer of a Melanoma patient whose disease is in Stage 4	I am the carer of a Melanoma patient whose disease is in currently NED (no evidence of disease)	I am the carer of a Melanoma patient whose disease is in n/a
Other	Other Stage 1	Other Stage 2	Other Stage 3	Other Stage 4	Other currently NED (no evidence of disease)	Other n/a

If other, please specify

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* 3. Your/ the patient's Melanoma is

Cutaneous Melanoma/ Melanoma of the skin

Ocular/ uveal/ choroideal Melanoma/ Melanoma of the eye

Acral Melanoma/ Melanoma that started on hand or feet

Mucosal Melanoma/ Melanoma that started on the inner body surface

I don't know

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* 4. What is your profession?

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* 5. Are you working with a Melanoma advocacy group?

Name of the group

Country

Website

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* 6. How much Melanoma Advocacy experience do you have?

Just getting into it

Some experience but want to learn more

Already running Melanoma advocacy projects for some time

Other (please specify)

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* 7. How much have you been involved in HTA?

Not at all

Somewhat occasionally

ad hoc interaction

organised interaction, e.g. as member of committees etc

I don't know what HTA is

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* 8. The Workshop is in English - what is your level of English?

Native English Speaker

Very good level of written and spoken English

School Level English

Poor English but happy to try

No English

Native English Speaker

Very good level of written and spoken English

School Level English

Poor English but happy to try

No English

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* 9. One of the aims of this workshop is to connect European Melanoma advocates. Are you happy to share your email address with the other participants of the workshop?

Yes

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* 10. I have read and accepted the Participant Agreement.

Yes

PARTICIPANT'S AGREEMENT

Participation in the Krusenberg 2018 workshop

22nd- 25th November 2018, Krusenberg Herrgård , Sweden

Financial Support
MPNE agrees to cover registration, full-board accommodation for 3 nights and travel expenses up to a maximum of 400 Euro for participants selected to attend the Workshop. It is the responsibility of the participants to declare the grant provided by MPNE to their financial institution if applicable.

Please note we will inform you if your application has been successful within 3 working days after the deadline, and you will then receive further logistical information. Please do not book travel/flights until you have been informed of your successful registration.

Travel
MPNE will provide travel grants to participants, up to a maximum of 400 euro (this amount includes all travel expenses - train, flight, car- for economy/ 2nd class travel). Participants will be responsible for booking their own travel and they will be reimbursed after attending the full conference on completion of the reimbursement form together with travel receipts. Please note that participants are responsible to arrange their own travel and airport transfers! We will however share forms on Slack to share taxis from the airport to arrive at Krusenberg.

Accommodation
MPNE will book accommodation for you at the conference venue for 3 nights (Thursday, Friday and Saturday). Accommodation will be full-board, in single rooms. Participants will be liable for all extra costs. Should participants desire to stay extra nights, these need to be directly arranged at the hotel and covered by participants themselves.

Filming/ photos
By accepting their place at Krusenberg 2018, participants agree to being filmed/ photographed at the conference and those images to be used for MPNE work, like the conference documentation. We will not prominently use single photos of you without asking but that just becomes impossible for group pictures!

Insurance
MPNE bears no responsibility for untoward events in connection with, before, during and after the conference. Participants are advised to take out their own personal and travel insurance coverage.

Attendance and Preparation
By accepting the Participant's Agreement, participants declare that they will attend the full workshop in Krusenberg. This workshop will produce concrete projects for the entire MPNE network for the benefit of Melanoma patients. Preparation and participation are therefore crucial. Participants agree to prepare appropriately for the workshop.

The online version is available here-http://www.melanomapatientnetworkeu.org/participant-agreement-krusenberg-2018.html

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* 11. Is there anything else you would like us to know ?

WE LOOK FORWARD TO SEEING YOU IN KRUSENBERG!
Bettina, Gilly and Violeta