First Name*

Last Name*

Legal name if not listed above

Email Address*

Mobile*

Street Address*

City*

State*

Country*

Zip Code*

Primary Degree*

Employer / Institution*

Occupation*

Workplace Setting*

What is your primary specialty?*

National Provider Identifier (NPI)*

Which discussion topic are you interested in attending?*

Are you a member of Washington State Medical Oncology Society (WSMOS) ?*

I understand that this discussion is IN-PERSON only, there are no virtual options.*

Emergency Contact Name*

Emergency Contact Phone Number*

Please indicate your dietary restrictions and we will do our best to accommodate your request*

Vegetarian

Vegan

Dairy Free

Gluten Free

Fish and/or Shellfish Allergy

Nut Allergy

No dietary restrictions

Other (Must specify in next question.)

Have a dietary restriction not listed? Please note it below. To request an offsite meal, email us at registration@targetedonc.com and list it here so we can do our best to accommodate. Same-day requests may not be accommodated. Thanks for your understanding!

I am registering for this event because I received an invitation from*

Please provide the name of the colleague that invited you to this meeting.

Did you receive an invitation for this meeting directly from the Moderator?*

If yes, please provide the name of the moderator that invited you to this meeting.

I am interested in being contacted by the Targeted Onc editorial team via email for potential content contributions, such as interviews or collaborative projects, should suitable opportunities become available.

I would like to receive exclusive text communications from Targeted Onc to the mobile number provided.

By checking this box, you agree to the Targeted Onc terms and conditions, Privacy Policy, understand that your information will be shared with the partnering State Society for this event, and understand that you will be receiving email communications.

By attending a Targeted Onc Community Case Forum™ ("Event"), all participants, attendees, sponsors, and guests ("you") create an agreement between you and Targeted Onc regarding the use and distribution of your image, including but not limited to your name, voice, and likeness ("Image"). By attending the Event, you acknowledge and agree that photographs, video, and/or audio recordings may be taken of you and you grant permission to Targeted Onc (and its agents) to utilize, in perpetuity, your Image in any electronic or print distribution, or by other means hereinafter created, both now and in the future, for any lawful purpose as determined by Targeted Onc.

By submitting this form, you agree to receive recurring automated marketing text messages (e.g. AI content, cart reminders) from Targeted Onc at the number you provide. Consent not a condition of purchase. We may share info with service providers per our Privacy Policy. Reply HELP for help & STOP to cancel. Msg frequency varies. Msg & data rates may apply. By submitting this form, you also agree to our Terms (incl. arbitration) & Privacy Policy.

Registration Request