Living with Lynch 2023 participant application

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Thank you for your interest in participating in the 2023 Living with Lynch Patient Workshop. The in-person small group event will take place October 12-15, 2023 in New York City, hosted by AliveAndKickn and the Colon Cancer Coalition. The weekend features speakers from several of NYC's top cancer centers.

Lynch syndrome patients are invited to apply. After a thorough review process, we will be selecting a diverse group of about a dozen individuals to join us in NYC. The application will be open through the middle of April and the selection process will go through the middle of June.

Below is the preliminary weekend schedule:

Thursday 10/12/23
• Attendees Arrive
• Happy Hour/Dinner near Hotel

Friday 10/13/23
• 8:00am Breakfast
• 8:30am – 5:00pm Professional roundtable discussions, Filming participant stories
• 6:00pm – Dinner/Reception

Saturday 10/14/23
• 8:00am Breakfast
• 8:30am-12:30pm Breakout groups/advocacy training/Filming participant stories

• 12:00pm Lunch
• 1:00-5:00pm TBD
• 6:00pm Dinner

Sunday 9/18/22
• 8:00am – 12:00pm Get Your Rear in Gear 5K event in Brooklyn, NY
• 12:30pm Close
• Attendees depart

Please fill out the application below as we work to put together a diverse and engaging small group of Lynch Syndrome Advocates to participate in person. Thank you

Email *

First Name *

Last Name *

Address *

Phone *

Date of Birth *

YYYY

My gender (self-identified) is...

Female

Male

Prefer not to say

Other:

Clear selection

Pronouns: Check one or more options for the set(s) of pronouns you want people to use to refer to you.

he, him, his

she, her, hers

they, them, theirs

Other:

My race or origin is...

American Indian or Alaskan Native (i.e. Navajo, Mayan, Tlingit, etc.)

Asian (i.e. Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, etc.)

Black or African American (i.e. African American, Haitian, Nigerian, etc.)

Hispanic, Latino, or Spanish origin (i.e. Mexican, Mexican American, Puerto Rican, Cuban, Argentinian, Colombian, Dominican, Nicaraguan, Salvadorian, Spaniard, etc.)

Native Hawaiian or Other Pacific Islander (i.e. Native Hawaiian, Guamanian or Chamorro, Samoan, Fijian, Tongan, etc.)

White (i.e., European, Middle Eastern, Northern Africa, etc.)

Some other race or origin

Clear selection

I have been diagnosed with a Lynch Syndrome related genetic mutation...

Yes

Don't Know

Clear selection

I was diagnosed with Lynch Syndrome in...

Age of diagnosis...

I was diagnosed with the following Mutation Type...

MLH1

MSH2

MSH6

PMS2

EPCAM

Unknown Variant (Variant of unknown significance)

Don't Know

Clear selection

I have been diagnosed with a primary...

Colorectal cancer

Endometrial(uterine) cancer

Bladder cancer

Breast cancer

Esophagus/throat cancer,

Kidney/renal/pelvis cancer

Leukemia/blood cancer

Lung cancer

Lymphoma

Oral cavity/oropharyngeal cancer

Ovarian cancer

Pancreatic cancer

Prostate cancer

Melanoma skin cancer

Non-melanoma skin cancer (basal cell, squamous cell)

Thyroid cancer

Other cancer

Never been diagnosed with cancer

My Other cancer was...

The following biological family member(s) have had cancer...

Father

Mother

Son(s)

Daughter(s)

Brother(s)

Sister(s)

Maternal Grandfather (mother's father)

Maternal Grandmother (mother's mother)

Maternal Aunt(s) (mother's sister(s))

Maternal Uncle(s) (mother's brother(s))

Paternal Grandfather (father's father)

Paternal Grandmother (father's mother)

Paternal Aunt(s)(father's sister(s))

Paternal Uncle(s) (father's brother(s))

Cousin(s)

Please tell us your FAMILY story of Lynch Syndrome/Cancer (400 words or less)

Please tell us your PERSONAL story of Lynch Syndrome/Cancer (400 words or less)

Why do you want to become a Lynch syndrome ambassador/advocate?

In order to be cognizant of any NYC COVID guidelines that may be in place in September, and to recognize patients that join us that may be immunocompromised, we need to access applicant's ability to travel, participate and levels of protection.

Have you been or do you plan to be fully COVID vaccinated by the Living with Lynch Patient Workshop, October 12-15, 2023?

I am already fully vaccinated

I plan to be fully vaccinated by September

I will not be vaccinated due to medical or other reasons.

Clear selection

Do you believe you will be able to fully participate in all the activities throughout the weekend including full days of roundtable discussions, telling your story on camera, attending the Get Your Rear In Gear 5K (running/walking the 5K is optional) as part of Team Lynch Syndrome, evening social activities (primarily dinners), etc.

I will be able to fully participate

I may need accomodations for some of the schedule

Other:

Clear selection

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