RareShare Webinar/Podcast Registration Form-Large Granular Lymphocytic Leukemia-Nov 2015

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Will you attend the webinar or podcast *

Yes, sign me up for the webinar

No don't sign me up, but I have a question

First Name *

Last Name

What brings you to webinar or podcast series? Check all that apply.

I have or someone close to me has Large Granular Lymphocytic Leukemia

I'm interested in knowing more about the Large Granular Lymphocytic Leukemia research/treatment

I'm interested in learning about the advancements in rare disease research.

Other:

Your Email (For the details about the webinar or live podcast, and then we will not contact you again [or store the email] unless you check that you want to hear more about us!)

What is your phone number?

If you would like to submit question for our panelists to answer, write them here:

Will you be comfortable using phone/internet/computer during the podcast or webinar session?

Yes

Other:

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We might feature your question. If so, would you be okay with us using your first name and last initial and where you are from when asking the question?

Yes, of course!

No, I'd prefer not.

Feel free to use my name, but not where I live.

Feel free to use where I live, but not my name.

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If so, country and/or state of residence:

If you would like to hear more about RareShare or RGI, check yes and we will send you an email with more information!

Yes, I would love to hear more about RGI and RareShare

Yes, I would love to hear more about RareShare Only

I would love to hear about Large Granular Lymphocytic Leukemia Only

No thanks!

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