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New and Emerging Therapies - Waterloo Webcast
Thank you for taking the time to register for the Waterloo webcast gathering of the "New and Emerging Therapies" on Saturday, June 7, 2014 at the Waterloo Inn Conference Hotel.
*
1.
CONTACT INFORMATION
(Required.)
FIRST NAME
LAST NAME
ADDRESS 1
ADDRESS 2
CITY
PROVINCE
POSTAL CODE
PHONE NUMBER
EMAIL ADDRESS
*
2.
I am a
(Required.)
Patient/Survivor
Supporter/Caregiver
Healthcare Professional
Student
Other (please specify)
3.
If a Patient, please indicate your diagnosis
Hodgkin
Follicular
Diffuse Large B-Cell
Marginal Zone/MALT
Mantle Cell
CLL/SLL
Burkitt's
Waldenstrom's Macroglobulinemia
Transformed
Peripheral T-Cell
Cutaneous T-Cell
NK-Cell
I don't know
Other Indolent, Aggressive, or T-Cell lymphoma (please specify)
4.
If a Healthcare Professional, please specify.
5.
Please indicate your age
6.
How did you hear about this event?
*
7.
How many guests will be accompanying you?
(Required.)
0
1
2
3
8.
Help us improve our events! Please indicate below what you would like to know more about lymphoma or living with lymphoma:
9.
Would you be interested in Lymphoma Canada’s volunteering opportunities? These could include volunteering at an event, performing administrative functions, or being a mentor to others touched by lymphoma.
No thank you.
Yes, please contact me!
