Registration for the 2019 Cancer Awareness Day at the Virginia General Assembly
Registration for participation in the 2019 Virginia Childhood Cancer Awareness Day
Email address *
Name
Address
Phone Number
Please select one that best describes you.
Which treatment center are you affiliated with?
Do you know who your legislators are in your district? *
If not, click this link to determine who are your legislators: https://whosmy.virginiageneralassembly.gov/
Name of State Delegate
Name of State Senator
Are you registering additional people?
If registering additional people in your household, please include their names and ages below.
Do you or anyone in your party have any dietary restrictions? *
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