CancerCare Manitoba Prevention & Screening Event and Education Request Form

Tell us about your request.

Question Title

* 1. Requestor's Contact Information

Name

Organization

Address

City/Town

Province

Postal Code

Email Address

Phone Number

How people do you expect to attend?

Question Title

* 2. What is the date and start/end time of your session? If you have multiple options for dates, please list.

Question Title

* 3. What type of session is the request for?

Education session

Booth staffed

Exhibit materials (no staff)

Other (please specify)

Question Title

* 4. Who is the target audience for this session?

General public

Healthcare providers

Student healthcare providers (nurses, physicians, etc.)

Other (please specify)

Question Title

* 5. Identify the age category MOST of your target audience fits into?

Under age 21

21-49

50-65

65+

Question Title

* 6. The audience MOSTLY identifies as:

Male

Female

Evenly male and female

Trans*, non-binary, gender diverse

Other (please specify)

Question Title

* 7. Tell us anything else we should know about the intended audience.

Question Title

* 8. What topics should we cover? Check all that apply. Note: we are only able to provide information on areas within our scope.

breast cancer screening

cervical cancer screening

colorectal cancer screening

cancer prevention

Question Title

* 9. By what date do you need a response to your request?

Question Title

* 10. Are there any fees/costs we should be aware of to attend this event? (i.e. parking, admission, etc.)

Thank you for your request. Our team may need to contact you for clarification.
CancerCare Manitoba Prevention and Screening
#5-25 Sherbrook Street, Winnipeg MB, R3C2B1
Screening@cancercare.mb.ca
1-855-95-CHECK