Pinked Perspective Empower Hour Workshop
Thank you for your interest in our workshops designed to empower local Pink Warriors to regain function and strength following a breast cancer diagnosis. In completing the following form it is understood by you (the participant) that the purpose is to provide education and not direct treatment with our workshops. 
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Email *
Full Name *
Mailing Street Address *
City *
State *
Zip Code  *
Have you attended a Pinked Perspective Empower Hour Workshop in the past?  *
Breast Cancer Diagnosis Date *
Type of Breast Cancer (include any specifics that may apply)
Have you undergone surgery?  *
Type of Reconstruction  *
Have you received any other treatment for breast cancer?  *
Required
At which treatment center(s), do you receive care? 
What is one recommendation you would offer (medical professional, intervention or support) that made a significant difference in your breast cancer journey/recovery from treatment? 
Are there other topics you would like to hear about during future Empower Hour Workshops? 
How did you hear about the Empower Hour Workshop? 

LIABILITY WAIVER: I recognize that participation in this activity may involve certain hazards. I understand that I should not participate unless medically cleared/able. I assume all risks associated with participating in this event, including but not limited to: injury, falls and contact with other participants, and these risks being known and appreciated by me. I have read this waiver and knowing these facts, I waive and release organizers of the Empower Hour Workshop, Pinked Perspective, Inc, Christy Asonglefac, DPT,  volunteers, and all sponsors of all claims, damages, demands and any action whatsoever in any manner arising from my participation in this event. Further, I grant the use of any photographs, motion pictures, recordings, or any other record of this event for legitimate purposes.
I agree to the above Liability Waiver. *
Required
Thank for you for registering! We look forward to seeing you soon!
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