Thank you for your interest in the Family Medicine Education Consortium (FMEC) Young Breast Cancer Survivors (YBCS) Learning Collaborative project. Please complete the simple form below to ensure you receive additional information on the project. This is not a commitment to participate.

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* 1. First Name

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* 2. Last Name

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* 3. Degree(s)

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* 4. Specialty/Practice

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* 5. Email

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* 6. Clinic/Health System/Training Program Name

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* 7. Are you interested in participating as an individual clinic site, or do you represent a larger group of sites? Please briefly describe.

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* 8. How many providers (physicians, nurse practitioners, other care team members) do you anticipate might participate if you join the program? (Optional; estimates are expected).

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* 9. City (of Primary Clinical Site)

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* 10. State (of Primary Clinical Site)

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* 11. Please use the space below to ask any questions you have about the project, or contact FMEC CEO Scott Allen (scott.allen@fmec.net) with questions.

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