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UIEcnf4dSkMYK4xQvpotx9i7Tv

KanSurvive 2.0 Cancer Survivorship ECHO Series Registration

This form will register you for all sessions listed below.

Continuing education credits will be provided for sessions attended.

Session 1

Breast Cancer Survivorship in Primary Care Practice

Guest Speaker: Anne O'Dea, MD

Thursday, October 9, 2025 @ noon-1pm CST

Session 2

Prostate Cancer Survivorship in Primary Care Practice

Guest Speaker: Richard Fantus, MD

Wednesday, October 22, 2025 @ noon-1pm CST

Session 3

Lung Cancer Survivorship in Primary Care Practice

Guest Speaker: Michal Reid, MD

Wednesday, November 5, 2025 @ noon-1pm CST

Session 4

Colorectal Cancer Survivorship in Primary Care Practice

Guest Speakers: Allen Greiner, MD & Chelsea Johanson, PA-C

Wednesday, November 12, 2025 @ noon-1pm CST

Date registered:

M-D-Y

First Name:

Last Name:

Email Address:

Phone Number:

Please select which best describes your employer/organization:

Other, please specify:

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Practice / Organization Address:

Practice / Organization City:

Practice / Organization State:

Practice / Organization Zip Code:

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County of Residence:

Title/Professional Role:

Credential(s):

APRN

CHW

LPN

LSCSW

MA / PCT

MD / DO

MPH

PhD

None

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Other credential(s):

Please list any questions or topics you would like to see covered during the session:

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I understand the Masonic Cancer Alliance collects registration, participation, questions/answers, chat comments, and poll responses for some programs. This information may be used for reports, maps, communication, surveys, quality assurance, evaluation, research, and/or to inform new initiatives. Individual data will be kept confidential.

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Multimedia Authorization And Release Form

The University of Kansas Medical Center ("KUMC") publicizes and promotes its activities in various media formats for general educational use and for the general public in the areas of research, patient care, and service. To accomplish this goal, KUMC requests persons to authorize KUMC to record and to use their name, likeness, voice, and/or performance by any means of recording, including, without limitation, photography, video recording, and/or quoted statements.

In the interest of furthering the above purpose, the undersigned agrees as follows:

1) To authorize KUMC to record my name, likeness, voice, and/or performance by any means of recording, including, without limitation, photography, video recording, and/or quoted statements, made as a result of the KanSurvive 2.0 Cancer Survivorship in Primary Care ECHO Series.

2) To authorize KUMC to use my name, likeness, voice, and/or performance by any means of publication, including, without limitation, publication in the form of published media articles, videos, newsletters, brochures, websites, Facebook, Twitter, Instagram and other social media channels owned or operated by KUMC or a media outlet;

3) To not receive any consideration, including, without limitation, royalties and/or paymentsfrom KUMC or its related entities for such recordings and use by KUMC of my name, likeness, voice, and/or performance in any publication;

4) KUMC has all rights, title, and interest to, and the undersigned herby assigns to KUMC any rights of the undersigned to any recording and any use of the recording made pursuant to this form, and KUMC is authorized to control distribution, editing, and use of such recording; and

5) To release and hold harmless KUMC, KUMC's related entities, and their agents, personnel, trustees, directors, officers, and employees against any and all claims for loss, damages, or injuries as a result of participating in the activities anticipated by this form, including, without limitation, the recording, use, and publication of the name, likeness, voice, and/or performance of the undersigned.

Signature:

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Date:

M-D-Y

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