Registration Fee Waiver Application 
 
Saturday, September 27, 2014
Pennsylvania Convention Center
1101 Arch Street, Philadelphia, PA 19107
 
Living Beyond Breast Cancer will provide a limited number of registration fee waivers to this conference.
LBBC is pleased to recognize Triple Negative Breast Cancer Foundation's support of fee waivers
for people diagnosed with triple-negative disease.
 LBBC is pleased to recognize Susan G. Komen’s support of fee waivers for people diagnosed with breast cancer.
Applications will be reviewed on a rolling basis until funds are depleted.
 
  Applications for fee waivers are closed.
There will be a limited amount of fee waivers available on site.

 

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 breast cancer. Limited fee waivers are available for caregivers and healthcare providers.
  • 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 (855) 807-6386. 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.
  • Completed applications should be submitted online using the form below and should be received no later than Thursday, September 18

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 three flowers. If this does not appear, re-check the application and completed 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)
 Individual who has been diganosed with breast cancer
 Caregiver, family member, friend
 Health professional
If a caregiver, name of associated conference participant: 
Year of breast cancer diagnosis (if applicable): 
WERE YOU DIAGNOSED WITH TRIPLE-NEGATIVE BREAST CANCER?*
Please make a selection.
 Yes
 No
 I don't know
WERE YOU DIAGNOSED WITH HORMONE RECEPTOR-POSITIVE BREAST CANCER?*
Please make a selection.
 Yes
 No
 I don't know
WERE YOU DIAGNOSED WITH HER2-POSITIVE BREAST CANCER?
Please make a selection.
 Yes
 No
 I don't know
HAVE YOU BEEN DIGANOSED WITH METASTATIC (STAGE IV) BREAST CANCER?*
Please make a selection.
 Yes
 No
 I don't know
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 $50:* 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 three flowers. 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.