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.

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* 1. CONTACT INFORMATION

FIRST NAME

LAST NAME

ADDRESS 1

ADDRESS 2

CITY

PROVINCE

POSTAL CODE

PHONE NUMBER

EMAIL ADDRESS

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* 2. I am a

Patient/Survivor

Supporter/Caregiver

Healthcare Professional

Student

Other (please specify)

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* 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)

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* 4. If a Healthcare Professional, please specify.

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* 5. Please indicate your age

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* 6. How did you hear about this event?

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* 7. How many guests will be accompanying you?

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* 8. Help us improve our events! Please indicate below what you would like to know more about lymphoma or living with lymphoma:

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* 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!