Advocate Form Financial Assistance

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* 1. First Name/Last Name

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* 2. Address/City/State/Zip

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* 3. Home Phone/Cell Phone

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* 4. Email

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* 5. Please explain what you hope to gain from this conference (for example, are you hoping to meet and connect with other survivors, gain new experiences, or assist in patient advocacy?).

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* 6. What other conferences, trainings, and advocacy programs have you been involved in?

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* 7. What attracts you to this program?

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* 8. What inspired you to want to be an advocate?

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* 9. Please provide a brief (no more than 250 words) narrative biography describing your cancer journey and involvement in cancer-related advocacy.

*Completion of this form does not guarantee conference registration.  You will be notified within 7 days of receipt regarding scholarship status.

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