Tell us about your request:

* 1. Requestor's contact information

* 2. Date of the event (approximate)

Start date
End date

* 3. Request type:

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

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

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

* 7. The audience MOSTLY identifies as:

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

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

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

* 11. Additional comments

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

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

* 14. How did you hear about us?

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