2025 Screening Event Signup

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SIGN UP TO HOST A HNC SCREENING OR AWARENESS EVENT

Join Head & Neck Cancer Alliance by hosting your own Head & Neck Cancer screening event.

Register your event by completing this form once for each event your organization/institution will host this year. For example, if you are hosting three events, you must complete this form three times (your information should auto-populate in the fields once you've filled out the form the first time).

HOST INFORMATION: provide your contact information.

Salutation (Dr., Ms., Mr., etc.)

First Name*

Last Name*

Suffix (MD, RN, Jr., Sr., etc.)

Job Title*

Institution/Organization Name*

Address*

Address 2

Country*

City*

State*

Postal Code*

Email Address*

Work Phone

Next: Event Info >>

SCREENING EVENT DETAILS

Event Details

Event Date*

Event Start Time*

Event End Time*

Event Name*

Event Description (Add additional event information, registration instructions, etc.)

Event Website

Event Type*

Venue Information

Venue Name*

Venue Address 1*

Venue Address 2

Venue Notes (Parking information, directions, etc.)

Venue Country*

Venue City*

Venue State/Province*

Venue Postal Code

Event Contact

Who should members of the public contact with questions about this event, such as how to register, where to park, etc.?

Event Contact First Name*

Event Contact Last Name*

Event Contact Email Address

Event Contact Phone

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Next: Shipping Info >>

Screening Kit

Each event is eligible to receive a free screening kit that includes screening forms, posters, volunteer t-shirts, educational materials, etc. Please note that we are no longer able to ship screening kits outside the US. Instead, materials will be sent electronically.

Would you like a screening kit for this event?

Yes No

If you need extra materials for this screening (for example, extra screening forms, brochures, or rack cards), please include your request below.

Should we send the screening kit to you?

Yes No

If the screening kit should go to someone other than you, please complete the fields below. If you indicated that the kit should ship to you, you do not need to complete the fields below.

Shipping Contact First Name*

Shipping Contact Last Name*

Shipping Contact Job Title

Shipping Contact Institution/Organization

Shipping Contact Address 1

Shipping Contact Address 2

Shipping Contact Country

Shipping Contact City

Shipping Contact State/Province

Shipping Contact Postal Code

Shipping Contact Email

Shipping Contact Phone

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ORGANIZATION NAME
ORG ADDRESS LINE 1
ORG CITY, ORG STATE ORG ZIP
ORG CONTACT PHONE
ORG CONTACT EMAIL

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