Central Southern Virginia Colorectal Cancer Roundtable Registration

12. Phone Number Type *This question is required.

• Office
• Cell
• Home

14. Please notify us regarding how you will participate in the Roundtable Kickoff on October 6th. Your confirmation email will include the specific address, room information and parking information for the selected location. *This question is required.

• I will attend the live event at New College Institute in Martinsville.
• I will participate in the event via broadcast at Centra Lynchburg General Hospital.
• I will participate in the event via broadcast at Centra Southside Community Hospital in Farmville.
• I will participate in the event via broadcast at Sovah Health in Danville.

15. What best describes the organization you are affiliated with? *This question is required.

• Health System/Hospital
• Primary Care Provider
• Federally Qualified Health Center
• Local Health District
• Community Organization
• Health Plan or Payor
• Employer
• Other