SGM Cancer CARE Registration

Name*

First Last

Name as you would like it to appear on badge*

Professional Email*

Personal Email*

BNGAP username*

If you have not yet registered for BNGAP.org, please write "Not registered"

Position/Title*

Degree*

Mailing Address*

City*

State*

Zip Code*

Country

Phone*

Race/Ethnicity*

Select all that apply

Specify if Race/Ethnicity not listed

Gender Identity*

Specify if Gender Identity not listed

Sexual Orientation*

Specify if sexual orientation not listed

Please list your pronouns as you would like them to appear on your name badge*

I would like to be included in a directory of researchers interested in SGM cancer research.*

Please select your SGM cancer research interests*

Emergency Contact. Please provide name, relationship, and phone number*

We will supply you with a copy of the book, "Cancer and the LGBT Community." Please indicate your preferred version for delivery.*

Please indicate if you would like a printed or digital version of the workshop materials*

Please list any food allergies

Arrival Date*

Anticipated Hotel Arrival Time (N/A if not requiring a hotel stay)*

Departure Date*

Departure Time

Food Preference

Are there any reasonable ADA accomodations we can provide for you?

Please attach your headshot

Max. file size: 32 MB.

Please include your professional bio (200 word maximum)

Do you consent to any photos taken during the workshop to include your image on workshop advertising and promotional materials?

Is there anything else you want us to know before you attend the workshop? Please describe here

Comments

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