Asian American, Native Hawaiian and Pacific Islander Cancer Survivorship Conference Registration, July 22 - 24, 2008, Burlingame, California
This form is for credit card payment only. Please use the printable version on other types of payments.
Fields marked with * are required.
Dr    Mr    Ms
*First Name:  *Last Name: 
Title/Position: 
Organization: 
*Street Address:
*City: *State:  *Zip: 
*Email:   
*Phone:  Fax: 
There will be PRECONFERENCE WORKSHOPS on the first day. To attend a preconference workshop and receive lunch, please add $25 to the registration.
You may choose up to 2 workshops:
Grant Writing for AA & NHPI Community Based Organizations
 From Cancer Survivor to Cancer Advocate: Policy Advocacy
 Media Spokesperson
 Tools & Strategies for Developing and Sustaining AA & NHPI Cancer Support Groups
 Cancer Clinical Trials for AA & NHPI Communities
On DAY 2 there will be BREAKOUT SESSIONS
Please choose one session:
Palliative Care, End-of-life and Cancer
How Cancer Impacts AA & NHPI Families and Caregivers
How to Navigate through Cancer Information
Special Needs:
Please list any dietary restrictions (allergy, vegetarian, etc.) and other special needs (language translation):
Emergency Contact:
Name: 
Phone:    Relationship:
*Registration Fees

Select the registration that applies to you:
   $125 for business/industry representative, government representatives, for-profit companies
   $75 for community based organization staff, non-profit organizations, faith based organizations
   $25 for cancer survivors, caregivers, students, disabled, seniors

 Select below for preconference workshops:
    $25 to attend preconference workshops on July 22nd

CANCELLATION: $25 processing fee charge (No refunds after June 22, 2008)
  

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