The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

oUzWgPNRU6gZAtW8jWCn3YPziK

Thank you for submitting your RSVP to the MCA Annual Meeting. Kindly fill out the information below regarding your attendance.

When: Friday, April 24 2026

Where: Olathe Health Education Center, 21201 W 152nd St., Olathe, KS

Please contact Lety at 913-945-6686 or kucc-mca@kumc.edu with any questions.

Accessibility Statement - The Masonic Cancer Alliance supports a diverse community including those with visual, hearing, physical, and learning disabilities. We are committed to providing an inclusive environment for all participants. If you need accessibility assistance, please contact Traci McCarty.

Attended the 2026 MCA Annual Meeting?

Yes

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First name:

* must provide value

Last name:

* must provide value

Preferred name (for name tag) if different from above:

Title or professional role:

Email address:

* must provide value

Employer/Organization:

* must provide value

Other organization:

Organization address:

Organization city:

Organization state:

Organization zip code:

Phone:

Are you a KPPEPR partner?

Are you a member of PIVOT?

Will you need Continuing Education credits? (You will receive an email closer to the meeting date with a required form for CEs.)

* must provide value

Yes

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May we share your contact information with annual meeting attendees?

Yes

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Credentials:

* must provide value

APRN

BSN

LCSW

LSCSW

MPH

MSN

MSW

PhD

None

Other

Other credential(s):

Dietary restrictions:

* must provide value

None

Vegetarian

Vegan

Gluten-Free

Dairy/Casein-Free

Sugar-Free

Other (please specify)

Other dietary restrictions:

Food allergies (please list):

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.

* must provide value

I understand

I do not understand

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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; MCA Annual Meeting on April 24, 2026 at Olathe Health Education Center, 21201 W 152nd St., Olathe, KS

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.

* must provide value

I agree to multimedia authorization and release form

I disagree to multimedia authorization and release form

I've completed this registration on behalf of the named attendee and they are unable to sign.

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First name: ______

Last name: ______

Address:

City:

State:

Zip:

Phone: ______

Email: ______

IF COMPLETING ON BEHALF OF A MINOR:

Parent/Guardian Name:

Relationship to Minor:

Signature:

* must provide value

Add signature

Date:

* must provide value

M-D-Y

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