2026 Screening Event Signup

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SIGN UP TO HOST A HNC SCREENING OR AWARENESS EVENT

Support early detection and awareness by hosting a head and neck cancer screening or awareness event with the Head and Neck Cancer Alliance.

Please note: complete the registration form once for each event your organization plans to host. If you host multiple events, submit the form separately for each one. Your information will auto-populate after your first submission.

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

Please be careful here, as this part of the form might have auto-populated using the address information you provided on the previous page.

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.

Please be careful here, as this part of the form might have auto-populated using the address information you provided on the previous page.

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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