Event & Speaker Request Form
Triage Cancer can provide you with a single speaker for your educational event or multiple speakers on a variety of cancer survivorship topics through our Speakers Bureau. Triage Cancer can also provide event coordination and logistical support services for cancer survivorship educational events. Please complete the following form to help us understand your needs. A Triage Cancer team member will contact you shortly.
Are you requesting multiple speakers for your event?
Clear selection
Are you requesting assistance from Triage Cancer to coordinate your cancer survivorship educational event?
Clear selection
First Name *
Last Name *
Job Title
Organization Name *
Email Address *
Phone Number *
Event Location
City
State *
Event Name *
Event hosted by *
Date of event *
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DD
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Duration of the event *
Approximate number of attendees *
Is this a webinar/teleconference request? *
Topic(s) of Presentation *
Required
Audience
Choose disease stage/focus (check all that apply)
If requesting a preferred Triage Cancer speaker, please enter their name here.
Please indicate the honorarium amount available for the speaker. *
Will travel expenses be reimbursed? *
Please describe *
How did you hear about Triage Cancer's Speakers Bureau?
Additional Comments
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This form was created inside of Triage Cancer.