Registration Fee Waiver Application
8th Annual Conference for Women Living with Metastatic Breast Cancer
Enhancing your Health and Quality of Life
 
Saturday, April 26 - Sunday, April 27, 2014
Philadelphia Marriott West
111 Crawford Ave, West Conshohocken, PA 19428
 
Travel grants and fee waivers are now closed.
There will be a limited number of fee waivers available on site at the conference.
 
Living Beyond Breast Cancer will provide a limited number of registration fee waivers to this conference. Applications will be reviewed on a rolling basis until funds are depleted.
 

DO NOT COMPLETE THIS FEE WAIVER APLICATION if you apply for a travel grant!
All travel grant recipients receive a fee waiver with their approval.
 

  
Eligibility Critera

  • Applicants with a demonstrated financial need who, otherwise, would be unable to participate in this conference.
  • All applicants must briefly describe their financial circumstances and need for a conference registration fee waiver.
  • Priority will be given to applicants diagnosed with metastatic breast cancer.
  • Fee waivers for this conference are open to people living in the United States and Canada.
  • All information provided must be accurate. Any invalid information will result in the immediate termination of your application for a fee waiver.

General Information

  • If you register with a credit card before being approved, you will not recieve reimbursement for this expense. You will forfeit your registration fee waiver. No exceptions.
  • If you are approved for a fee waiver and decide not to attend the conference, please send an email to LBBCtravelgrants@leaddogonline.com or call (610) 645-4567. Not doing so may affect your eligibility for future fee waiver opportunities with LBBC.
  • Applicants must complete conference evaluation forms and provide a brief testimonial statement that informs LBBC of the impact the conference had on the applicant. By applying for and accepting the registration fee waiver, recipients agree that testimonials may be used on LBBC's website or in future marketing materials.

Notification Process

All applicants will be notified by email or phone within ten (10) business days from the date the completed application was received. If you have any questions, please send an email to LBBCtravelgrants@leaddogonline.com.

REGISTRATION FEE WAIVER APPLICATION
You will know you have successfully submitted your registration fee waiver application when you see the picture of a tree. If this does not appear, re-check the application and complete sections in ALL CAPS.
*indicates required field
FIRST NAME:* 
LAST NAME:* 
Organization (if applicable): 
ADDRESS:* 
CITY:* 
STATE or CANADIAN PROVINCE:* 
ZIP CODE:* 
EMAIL ADDRESS:* 
PLEASE RE-TYPE YOUR EMAIL ADDRESS:* 
HOME PHONE:* 
Cell Phone: 
YEAR OF BIRTH:* 
Race/Ethnicity: White
 Black or African American
 American Indian or Alaska Native
 Asian or Asian-American
 Pacific Islander
 Hispanic, Latino or Spanish origin
 Multiracial or Multiethnic
DO YOU IDENTIFY YOURSELF AS A:*
(check all that apply)
 Woman who has been diagnosed with breast cancer
 Caregiver, family member, friend
 Health professional
If caregiver, name of associated conference participant: 
Year of breast cancer diagnosis (if applicable): 
HAVE YOU BEEN DIAGNOSED WITH METASTATIC BREAST CANCER:* Yes
 No
If you have metastatic breast cancer, please indicate your year of this diagnosis: 
If you have not been diagnosed with breast cancer, please briefly explain (100 words or less) your interest in attending this conference.
I NEED FINANCIAL ASSISTANCE TO COVER THE CONFERENCE REGISTRATION FEE OF $75:* Yes
 No
BRIEFLY (100 WORDS OR LESS) DESCRIBE YOUR FINANCIAL CIRCUMSTANCES AND NEED FOR A CONFERENCE REGISTRATION FEE WAIVER.*
BRIEFLY (100 WORDS OR LESS) DESCRIBE HOW YOU WILL UTILIZE THE INFORMATION YOU LEARN IN YOUR COMMUNITY?*


NOTE: If you have spam protection on your email account, please add LBBCtravelgrants@leaddogonline.com to your address book or check your spam folder for a reply to your request.

You will know you have successfully submitted your fee waiver application when you see a picture of a tree. If this does not appear, re-check the application form and complete the sections in ALL CAPS.

If this symbol appears at the top of the page once you submit your form, it means there has been at least one error. Please review the form, especially the required fields marked with an * to make sure that your form is complete and resubmit.