Registration Form

Thyroid Cancer Survivors' Workshop
FREE Event. You also may register on site at the workshop.
Sponsored by ThyCa: Thyroid Cancer Survivors' Association, Inc
 
  1. Please complete a separate form for additional family members or guests.
  2. Deadlines: On-line registration deadline is 2 calendar days before the event.

Notes: Please DO NOT use the 'back' button on your browser to leave this page! It could cause information to be deleted

    * Indicates required information
* Thyroid Cancer Survivors’ Workshops:

On-line registration is now closed for the following workshops:

  • Saturday, May 16th - San Diego/Southern California Workshop (San Diego, CA)
  • Saturday, May 16th - Mid-Atlantic Workshop (Takoma Park, MD)
  • Saturday, May 16th - TX/Southwest Workshop (Dallas, TX)
    • You may register on site Saturday, May 16th
Important: Go to www.thyca.org/conferences.htm and check your workshop's listing for additional information.
REGISTRANT'S INFORMATION:

(Complete this section as you would like your name-tag to appear):
*Salutation
*First Name
*Last Name
*Address
*City, State/Province, ZIP/Postal Code
*Country
*Area Code/Day Phone
*Area Code/Evening Phone
*Email
This will be used for your workshop confirmation. Please check for accuracy.
Note about Directory: It is sent by postal mail after the workshop to those attending. The Directory is only for personal, non-research, noncommercial use.
Include all the information above in the Workshop Directory
Include only my name
Include only my name and mailing address
Include only my name and email address
Leave me out of the Workshop Directory
OPTIONAL
Date of diagnosis:
Type of cancer (check all that apply):
Papillary Follicular Medullary Anaplastic
Variant:
Special Accommodations:

How did you learn about the workshop?

How did you learn about ThyCa (Thyroid Cancer Survivors' Association, Inc)?

Have you attended a ThyCa local support group meeting? Yes No

If yes, where?

Do you take part in a ThyCa e-mail support group? Yes No

If yes, which? Papillary/Follicular Medullary Anaplastic Pediatric
Advanced thyroid cancer Long-term survivors Caregivers ThyCa Mental Challenges
Childbearing and Thyroid Cancer Love, Loss, Legacy
I would like to help with future workshops and ThyCa projects.

Upon completion of this form, please click the 'Submit Form' button below,
and then wait a moment for an acknowledgement of your registration.

Please DO NOT click the submit button more than once
as this may result in a double entry.
To clear this form, please click the 'Reset' button below.