Greater REACH Patient Advocate's Symposium

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If you are interested in attending Going Beyond the Pink's Greater REACH Patient Advocate's Symposium (October 19-22, 2023), please complete this interest form. We'll follow up with registration information, scholarship information, and other related news as soon as more details are available.

Completion of this form indicates your interest in attending. It does not guarantee space or participation in the event. Please add info@goingbeyondthepink.org to your safe sender's email list and watch for future emails about the program.

Email *

First & Last Name *

I am a: (check all that apply) *

Patient in active treatment (surgery, chemotherapy, radiation)

Survivor (less than 2 years since active treatment)

Survivor (2-5 years since active treatment)

Survivor (5-9 years since active treatment)

Survivor (10+ years since active treatment)

Patient/Survivor (more than 1 breast cancer diagnosis)

Patient/Survivor (history of multiple types of cancer)

Caregiver (to breast cancer patient)

Caregiver (to patient with cancer other than breast cancer)

Physician/Oncologist/Oncology Staff Member

Nonprofit/Community Organization Representative

Cancer Patient Advocate

Other:

Required

I'm intersted in: *

attending the in-person Greater REACH Patient Advocate's Symposium

attending virtually/online only (if available)

attending regardless of whether the syposium is offered in-person or online

Required

Scholarship Need/Interest (check all that apply) *

I may need scholarship funding to cover the registration/event fee

I may need scholarship funding to cover transportation expenses

I may need scholarship funding to cover lodging expenses

I cannot attend without scholarship funding

I will not need scholarship funding to attend

Required

I'm interested because: *

Send me a copy of my responses.

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