register to attend in-person

Please fill out the below form to register for the September 13th Externally-led PFDD workshop on chemotherapy-induced hearing loss in pediatrics. We will follow up with more details, including hotel information and meeting agenda. There's no cost to register. Attendees are responsible for their own transportation expenses.

Name

First Name

Last Name

Additional attendees, if any:

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Which best describes you?

Please tell us a little about your personal or professional experience with childhood cancer and hearing loss.

If you or your child has or had cancer, please tell us which type. This information enables us to better prepare panel discussions and topics:

Affiliation, if any: (FDA, industry, patient advocacy organization, etc.)

How did you learn about this event?