Cancer Services Date of Event and Start Time Date of Event and Start Time: Date Date of Event and Start Time: Time All requests must be submitted at least 30 days prior to your response/print deadline date and event date. Set-Up Time Please include the time when we may arrive to set up. Name of Organization Official Name of Event/Opportunity Are you applying for multiple events with this request? Yes No Please list other dates and names of events. Requesting Organization Description Mission of Organization Organization Contact Main Phone Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Service Area of Organization Milwaukee County Other… Enter other… Please choose all that apply. Organization Website Event Description Please limit to 200 words. What is the goal of the program or event?? Audience Size - None -0-5051-150151-300301-500501-750751-10001000+ Target Audience for Event/Opportunity? Milwaukee County Other… Enter other… Please describe the age, ethnicity and gender of your target audience.? Will you need a presentation done in Spanish as well as English? Yes No What are you requesting for the event? Booth Speaker Screening event Dietitian General cancer information/education Breast cancer education Colorectal cancer education Lung cancer education Prostate cancer education Pig lung demonstration/display Strollin' Colon display Other… Enter other… How long has the event been in existence? - None -Less than one year1-2 years3-5 years6-10 yearsMore than 10 years How often does the event occur? How often does the event occur? - None -One timeQuarterlyAnnuallyOther… Enter other… Has Froedtert & MCW health network participated in this event in the past? Yes No If yes, when and for how many years? Are there any other presenters or sponsors for this event? Yes No If yes, name the other organizations. Please upload the event flyer (if available). Upload One file only.256 MB limit.Allowed types: pdf doc docx. Primary Contact Information This is the person who will coordinate the specifics of the program or event. Primary Contact Information Name? E-Mail Direct Phone Job Title: Please list any additional e-mail address we should copy on responses. Were you referred to this application by a Froedtert & MCW staff member? Yes No Name of Referring Froedtert & MCW Staff Member Event Overview What code is in the image? Enter the characters shown in the image. Submit Cancer Appointments (414) 805-0505 Request Appointment View Specialists Treatment Locations Contact Us Services Cancer Services Cancer Network Locations Cancer Rehabilitation Cancer Screening Patient Support 24-Hour Cancer Clinic Art Therapy Commmunity Outreach Cancer Outreach Program Request Quality of Life Center Prevention, Detection and Diagnosis Second Opinion Program Small Stones Wellness Center Small Stones Experts Specialty Cancer Programs Choosing a Cancer Physician Treatments Chemotherapy and Biotherapy Day Hospital Geriatric Oncology Immunotherapy Radiation Therapy Brachytherapy Frequently Asked Questions Gamma Knife Gamma Knife FAQ Image-Guided Radiation Therapy Stereotactic Body Radiation Therapy TomoTherapy Radixact Radiation Cancer Therapy Reconstructive Surgery Regional Cancer Therapy Hipec Surgical Oncology The Hub Model Clinical Trials & Research MR-Linac Tissue Banking Tumor Boards Doctors & Staff Share This:
