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LIVESTRONG Summit 2008 Application Form

The LIVESTRONG Summit will bring together delegates from across the country to be inspired, empowered and trained to lead community-centered efforts to help make cancer a national priority.

Through this application, the LAF will identify 1,000 current and potential leaders who are willing to champion the cause in their communities. You must be 18 years or older to apply. Incomplete applications will not be considered.

Already Registered? Click here to autofill this form
* required information
 
First Name:*
Last Name:*
Organization/Company Name:
Birth Date:*(mm/dd/yyyy)
Email:*
Gender: Female   Male  
Phone:*
Address Line 1:*
Address Line 2:
City:*
State:*
Province:
ZIP/Postal Code:*
Country:*
Profession:*
Are you applying on behalf of your organization? **:* Yes (list organization above)
No
Annual Income:*
Please select the racial and ethnic category or categories with which you most closely identify. Select all that apply:* African-American/Black
American Indian/Alaska Native
Asian
Caucasian/White
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Other
I prefer not to respond
Level of Education Completed:*
My Connection to Cancer:* I have or had cancer
Family member or Spouse or Partner
Caregiver
Friend or loved one
Healthcare provider
Health professional
Know someone with cancer
No connection
I prefer not to respond
Other
Cancer type(s):
Please select all the ways you have been involved with the LAF:* Donor
Fundraiser
Grant Reviewer
Grassroots Fundraiser
LAF Grantee
LIVESTRONG Army
LIVESTRONG Challenge
LIVESTRONG Day
LIVESTRONG Summit
Purchased Merchandise including LIVESTRONG wristbands
Volunteer
Other (please specify)
None of the above
If other involvement, please describe:
Please select the area that interests you most:* Grassroots Advocacy and Organizing
Fundraising
Civic Engagements and Elections
Other (please specify)
If other area, please explain:
Best Form of Contact:* Email
Phone
Postal Service
No Preference
Would you be willing to allow the LAF to follow-up with you after the Summit?:* Yes
No
After the Summit, are you comfortable being a LIVESTRONG representative in your community?:* Yes
No
In 100 words or less, please describe your experience with cancer and/or the cancer community:*
In 100 words or less, please describe any leadership experience you have had working/volunteering in the community:*
In 250 words or less, please explain why you want to attend the Summit:*
Create Username and Password
Username:*
Password:*
Verify password:*
Security Question:
Security Answer:*
Type the characters you see in the picture below:*
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By submitting this application form, I am agreeing to the terms defined in the waiver.
        

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