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?
Are you requesting assistance from Triage Cancer to coordinate your cancer survivorship educational event?
First Name
Your answer
Last Name
Your answer
Job Title
Your answer
Organization Name
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Email Address
Your answer
Phone Number
Your answer
Address
Your answer
Event Name
Your answer
Event hosted by
Your answer
Date of event
MM
/
DD
/
YYYY
Duration of the event
Your answer
Approximate number of attendees
Your answer
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 subject-matter expert, please enter their name here.
Your answer
Please indicate the amount of honorarium available for the speaker.
Required
Will travel costs and/or lodging expenses be reimbursed?
How did you hear about Triage Cancer's Speakers Bureau?
Additional Comments
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