Event and Education Request Form

Tell us about your request:

Question Title

* 1. Requestor's contact information

Organization or group making request: *

Event name: *

Event address: *

Event city/town: *

Event province: *

Event postal code: *

Email address:

Phone number: *

How many attendees do you expect? *

Question Title

* 2. Date of the event (approximate)

Start date

Date

Time

AM/PM

End date

Date

Time

AM/PM

Question Title

* 3. Request type:

Presentation

Booth staffed

Exhibit materials (no staff)

Other (please specify)

Question Title

* 4. Please provide us with some information about the event and the audience.

Event name

Event address

Number of expected attendees

Question Title

* 5. Who will be in your audience? (Check all that apply)

General public

Healthcare providers

Both

Other (please specify)

Question Title

* 6. Identify which age category MOST of your target audience fits into?

<21

21-49

50-65

65+

Question Title

* 7. The audience MOSTLY identifies as:

male

female

evenly both

Other (please specify)

Question Title

* 8. Tell us a bit more about the audience.

Question Title

* 9. What would you like to know more about? (check all that apply)

breast cancer screening (BreastCheck)

cervical cancer screening (CervixCheck)

colon cancer screening (ColonCheck)

cancer prevention

Other (please specify)

Question Title

* 10. List/describe any additional comments about what information your audience requires.

Question Title

* 11. Additional comments

Question Title

* 12. Are there any fees for us to participate? If yes, please list.

Question Title

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

Question Title

* 14. How did you hear about us?

Colleague

Social media

CancerCare Manitoba website

Other (please specify)

Thank you for your interest in cancer screening for breast, cervix and colon cancers.
We will be contacting you within 5 business days to discuss your request.
CancerCare Manitoba Screening Programs
5-25 Sherbrook St., Winnipeg, MB, R3C 2B1
1-855-95-CHECK (1-855-952-4325)
Screening@cancercare.mb.ca