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1. Requestor's contact information (Required.)

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2. Date of the event (approximate) (Required.)

Date
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Date
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4. Please provide us with some information about the event and the audience. (Required.)

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

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6. Identify which age category MOST of your target audience fits into? (Required.)

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7. The audience MOSTLY identifies as: (Required.)

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8. Tell us a bit more about the audience.

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

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

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11. Additional comments

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

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

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14. How did you hear about us? (Required.)

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

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