Support Group Chapter Speaker Request Form

NCAN OFFICIAL SUPPORT GROUP CHAPTER GUEST SPEAKER REQUEST FORM

We are excited that you have chosen to tap into one of the many benefits of being an NCAN Support Group Chapter. This form will assist you in securing a speaker for one of your local chapter meetings.

If you need assistance in filling out this form, please call us at 1 (866) 850-9555.

Benefits of having a guest speaker:

Bring Scientifically Valid Professional Presentations on Topics Critical to the Diagnosis and Treatment of NETs to Local Support Group Chapter Members
Relevant and valuable hour of education / Q&A before peer-to-peer sharing
No cost / low cost to NCAN
Attractive to members and potential members
Approximately 15 no cost presentations available
Once a chapter has scheduled a date, the other chapters have priority for availability. When all have had a chance to book, chapters may schedule another presentation.

Chapter Name

Choose your chapter from the dropdown list

Requestor Information

First Last

Your Email

Your Mobile Phone

I. Tell us your preference for presentation topics by dragging them into your order of preference:

“Carcinoid Syndrome Briefing” (Lexicon)
“Dietary Tips for NET Patients” (Lexicon) (Additional Lead Time & Cost Involved)
“Gallium68 Scan and PRRT Briefing” (AAA)
“The Right Amino Acids at the Right Time: Managing Diarrhea in NETs” (Entrinsic)

II. Date & Location of the next 5 meetings:

Date	Time	Location

Click on the "+" sign to the right of the TIME field to add more rows or the "-" sign to delete rows. Please make sure you submit five (5) dates and times.

III. Support Group Chapter Estimated Attendance for the presentation (small groups are ok):

10 or less
11 to 20
21 to 30
Over 30

Additional Comments:

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Support Group Chapter Speaker Request Form

CHAPTER SPEAKER REQUEST FORM

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Support Group Chapter Speaker Request Form