Living with Lynch 2021 participant application
Thank you for your interest in participating in the 2021 Living with Lynch Patient Workshop. We are optimistic that the in-person small group event will take place September 9-12, 2021 in Columbus, Ohio, hosted by AliveAndKickn, The Colon Cancer Coalition and Heather Hampel, MS, LGC, of The Ohio State Comprehensive Cancer Center. Whether or not the in-person event takes place, there will be virtual Living with Lynch Patient Webinars to follow up later in the fall of 2021.
Lynch syndrome patients are invited to apply, even if you have applied in the past. After a thorough review process, we will be selecting a diverse group of about a dozen individuals to join us in Columbus. The application will be open through the end of May and the selection process will go through the end of June.
Below is the preliminary weekend schedule:
• Attendees Arrive
• Dinner at Conference Hotel
• 8:00am Breakfast
• 8:30am – 5:00pm Professional roundtable discussions, Filming participant stories
• 6:00pm – Dinner
• 8:00am – 12:00pm Get Your Rear in Gear 5K event in Gahanna, OH
• 12:00pm Lunch
• 1:00-5:00pm Filming participant stories and Breakout groups OR PCORI Stakeholder event
• 6:00pm Dinner
• 8:00am Breakfast
• 8:30am-12:30pm Filming participant stories and Breakout groups OR PCORI Stakeholder event
• 12:30pm Close
• Attendees depart
Please fill out the application below as we work to put together a diverse and engaging small group of Lynch Syndrome Advocates to participate in person. Thank you
Date of Birth
My gender (self-identified) is...
Prefer not to say
My race or origin is...
American Indian or Alaskan Native (i.e. Navajo, Mayan, Tlingit, etc.)
Asian (i.e. Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Hmong, Laotian, Thai, Pakistani, Cambodian, etc.)
Black or African American (i.e. African American, Haitian, Nigerian, etc.)
Hispanic, Latino, or Spanish origin (i.e. Mexican, Mexican American, Puerto Rican, Cuban, Argentinian, Colombian, Dominican, Nicaraguan, Salvadorian, Spaniard, etc.)
Native Hawaiian or Other Pacific Islander (i.e. Native Hawaiian, Guamanian or Chamorro, Samoan, Fijian, Tongan, etc.)
White (i.e., European, Middle Eastern, Northern Africa, etc.)
Some other race or origin
I have been diagnosed with a Lynch Syndrome related genetic mutation...
I was diagnosed with Lynch Syndrome in...
Age of diagnosis...
I was diagnosed with the following Mutation Type...
Unknown Variant (Variant of unknown significance)
I have been diagnosed with a primary...
Oral cavity/oropharyngeal cancer
Melanoma skin cancer
Non-melanoma skin cancer (basal cell, squamous cell)
Never been diagnosed with cancer
My Other cancer was...
The following biological family member(s) have had cancer...
Maternal Grandfather (mother's father)
Maternal Grandmother (mother's mother)
Maternal Aunt(s) (mother's sister(s))
Maternal Uncle(s) (mother's brother(s))
Paternal Grandfather (father's father)
Paternal Grandmother (father's mother)
Paternal Aunt(s)(father's sister(s))
Paternal Uncle(s) (father's brother(s))
Please tell us your FAMILY story of Lynch Syndrome/Cancer (400 words or less)
Please tell us your PERSONAL story of Lynch Syndrome/Cancer (400 words or less)
Why do you want to become a Lynch syndrome ambassador/advocate?
In order to be cognizant of any Columbus, Ohio COVID restrictions and guidelines that may be in place in September, and to recognize patients that join us that may be immunocompromised, we need to access applicant's ability to travel, participate and levels of protection.
Have you been or do you plan to be fully COVID vaccinated by the Living with Lynch Patient Workshop, September 9-12, 2021?
I am already fully vaccinated
I plan to be fully vaccinated by September
I will not be vaccinated due to medical or other reasons.
Do you believe you will be able to fully participate in all the activities throughout the weekend including full days of roundtable discussions, telling your story on camera, attending the Get Your Rear In Gear 5K (running/walking the 5K is option) as part of Team Lynch Syndrome, evening social activities (primarily dinners), etc.
I will be able to fully participate
I may need accomodations for some of the schedule
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