Virtual In-Service Registration

Please complete the information below to reserve your spot for the Virtual In-Service training, hosted by Triage Cancer & Cancer and Careers.

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* 1. First Name

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* 2. Last Name

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* 3. Email Address

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* 4. Phone

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* 5. Street Address

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* 6. City

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* 7. State

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* 8. Zip Code

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* 9. Company/Organization (if applicable)

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* 10. Title (if applicable)

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* 11. How did you hear about this in-service program?

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* 12. What type of cancer do your patients have?

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* 13. Are you planning on requesting free continuing education credits?

Yes, from the American Nurses Credentialing Center's Commission on Accreditation

Yes, from the National Association of Social Workers

Yes, from the New York State Education Department State Board for Social Work

Yes, from the State California Board of Registered Nursing

Yes, a general certificate of attendance

N/A

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* 14. License number required for CEUs: (If you are not requesting CEUs, please write "N/A)

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* 15. What age range applies to you?

0-18

19-39

40-64

65+

Prefer not to share

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* 16. I identify my race/ethnicity as

Native American

Asian or Pacific Islander

Black or African American

Hispanic or Latinx

Middle Eastern or North African

White

Prefer not to answer

Other (please specify)

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* 17. What gender do you most identify with?

Woman

Man

Transgender

Non-binary/non-conforming

A gender not listed here

Prefer not to answer

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* 18. Do you need an accommodation?

Yes

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* 19. If you need an accommodation, please describe:

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50% of survey complete.