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 *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Event Location
Your answer
City
Your answer
State *
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 speaker, please enter their name here.
Your answer
Please indicate the honorarium amount available for the speaker. *
Your answer
Will travel expenses be reimbursed? *
Please describe *
Your answer
How did you hear about Triage Cancer's Speakers Bureau?
Additional Comments
Your answer
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