Please complete the information below to register for the Triage Cancer Insurance & Finance Intensive.

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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 of this training?

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* 12. Are you a (please check all that apply)

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* 13. What age range applies to you?

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* 14. I identify my race/ethnicity as

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* 15. What gender do you most identify with?

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* 16. Do you need an accommodation?

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

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* 18. Have you ever attended an event at which we presented? (check all that apply)

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* 19. Have you ever utilized Triage Cancer educational resources? (check all that apply)

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* 20. Why are you in need of this training? (Check all that apply)

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* 21. How do you plan to use the information from the event?

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* 22. Due to the interactive nature of this program, we require attendees to participate via computer with a webcam. If accepted, do you agree to participate via computer with a working camera?

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* 23. Given that space is limited, we are requesting that attendees participate in the entire event. Do agree to participate in the entire day?

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* 24. I agree that if I share the information learned at this event, I will provide proper credit to Triage Cancer. 

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