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CancerCare Manitoba Prevention & Screening Event and Education Request Form
Tell us about your request.
*
1.
Requestor's Contact Information
(Required.)
Name
Organization
Address
City/Town
Province
Postal Code
Email Address
Phone Number
How people do you expect to attend?
*
2.
What is the date and start/end time of your session? If you have multiple options for dates, please list.
(Required.)
*
3.
What type of session is the request for?
(Required.)
Education session
Booth staffed
Exhibit materials (no staff)
Other (please specify)
*
4.
Who is the target audience for this session?
(Required.)
General public
Healthcare providers
Student healthcare providers (nurses, physicians, etc.)
Other (please specify)
5.
Identify the age category MOST of your target audience fits into?
Under age 21
21-49
50-65
65+
6.
The audience MOSTLY identifies as:
Male
Female
Evenly male and female
Trans*, non-binary, gender diverse
Other (please specify)
7.
Tell us anything else we should know about the intended audience.
*
8.
What topics should we cover? Check all that apply. Note: we are only able to provide information on areas within our scope.
(Required.)
breast cancer screening
cervical cancer screening
colorectal cancer screening
cancer prevention
9.
By what date do you need a response to your request?
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
