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Support Group Chapter Speaker Request Form
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
West Chapter 1
West Chapter 2
West Chapter 3
Central Chapter 1
Central Chapter 2
Central Chapter 3
East Chapter 1
East Chapter 2
East Chapter 3
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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Your ticket for the: Support Group Chapter Speaker Request Form
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Support Group Chapter Speaker Request Form
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