The Greater New York City Affiliate of the Susan G. Komen Breast Cancer Foundation BREAST HEALTH WORKSHOP REGISTRATION FORM ORGANIZATION CONTACT *Person present at workshop for our speaker to meet PHONE EMAIL. PLEASE PROVIDE A BRIEF DESCRIPTION OF THE MISSION OF YOUR ORGANIZATION ORGANIZATION WEB ADDRESS (if applicable) PREFERRED WORKSHOP DATE / PREFERRED TIME* - (Day of Week/Date) *Provide a 1 hour time slot as the presentation takes 1hour. WORKSHOP LOCATION: (NAME OF HOST ORGANIZATION/BUILDING) Between and (STREET ADDRESS) (Avenue/Street) (CITY) (STATE) (ZIP) DOES UPS PICK UP PACKAGES ON A REGULAR BASIS AT THE WORKSHOP LOCATION? Yes No EMERGENCY CONTACT* EMERGENCY PHONE *Our volunteer should be able to call this person at the emergency phone number in case of an emergency on the day of the workshop. WHAT IS THE CLOSEST SUBWAY AND BUS STOP TO THE WORKSHOP LOCATION? (SUBWAY STOP) (BUS STOP) PROVIDE DIRECTIONS FROM THE SUBWAY STOP AND THE BUS STOP TO THE LOCATION NUMBER OF PARTICIPANTS EXPECTED AT WORKSHOP PLEASE DESCRIBE THE TYPE AND FORMAT OF THE WORKSHOP (e.g. brown bag lunch, informal discussion, etc.) WILL THERE BE ADDITIONAL SPEAKERS? PLEASE DESCRIBE THE EXPECTED AUDIENCE (e.g. gender, age, race, religion, breast cancer survivors, education level, languages spoken other than English, etc.) 1
PLEASE LIST WHICH FACTS FOR LIFE SHEETS YOU WOULD LIKE IN ADDITION TO THE GENERAL BREAST HEATLH MATERIAL THAT ARE PROVIDED AT ALL BREAST HEALTH WORKHOPS. THE LIST CAN BE FOUND ON FACTS FOR LIFE SHEETS GENERAL DESCRITPIONS PAGE (Please NOTE that we have a limited supply so please select which facts for life sheets would be helpful for your particular group. We will do our best to accommodate requests.) HOW SHOULD THE SPEAKER DRESS? (e.g. business casual, suit, etc.) DO YOU HAVE ACCESS TO A SLIDE PROJECTOR? SLIDE TRAY? TV/VCR? HAS YOUR ORGANIZATION EVER FORMED A TEAM FOR THE NYC RACE FOR THE CURE? Yes No IF YOU HAVE NOT, WOULD YOU LIKE TO BE ADDED TO OUR TEAMS MAILING LIST? Yes No HOW DID YOU FIND OUT ABOUT OUR SPEAKERS BUREAU/FREE BREAST HEALTH WORKSHOPS Flyer Web site Komen Connection Newsletter Other: SEND BREAST HEALTH MATERIALS TO: (ATTENTION) (ORGANIZATION NAME) (STREET ADDRESS) (CITY) (STATE) (ZIP CODE) PHONE FAX EMAIL THANK YOU FOR YOU EFFORTS IN RAISING AWARENESS ABOUT BREAST CANCER! WE WILL CONTACT YOU ONCE WE HAVE RECEIVED THIS COMPLETED FORM. PLEASE FAX TO ALYSSA LEVENE AT 212-560-9598 FOR OFFICE USE ONLY 2
Breast Health Workshop Summary Goals: To Raise Awareness about Breast Cancer, life-saving early detection practices, and our Foundation in the New York Community by providing Free Breast Health Workshops. Outline: I. Presentation A. Introduction to Komen History, Mission, and Activities B. General Information about breast cancer C. Key Early Detection Practices D. Breast Cancer Treatments E. Define Common Breast Cancer Terms F. New Screening Methods on the Horizon G. Breast Cancer Advocacy and Volunteer Opportunities H. Q&A II. Demonstration of the Breast Self-Examination III. Viewing of the Breast Health Basics and BSE Videos (Optional) IV. Distribution of breast health literature General Information: -The entire breast health presentation lasts about 1 hour. -The breast health presentation will be conducted by the Komen Greater NYC Speaker's Bureau, who have been trained to conduct breast health workshops and to provide Breast Self-Examination Instruction. -All breast health literature, ribbons, and breast models will be provided by Komen Greater NYC. If you would like further details on our breast health workshops, please contact Alyssa Levene via phone at 212-560-9590X221 or via e-mail at alyssal@nyraceforthecure.org. 3
Facts for Life Sheets General Descriptions alternative & complementary therapy describes and discusses different types of alternative and complementary therapies axillary lymph nodes explains the relationship between the axillary nodes and treatment of breast cancer benign breast changes describes fibrocystic changes and other benign breast conditions and explains their relationships to breast cancer biopsy discusses the role of biopsy in determining a diagnosis of breast cancer and explains the different types of biopsies breast cancer detection explains the importance of early detections and specific methods of detection breast cancer facts presents what is currently known about breast cancer breast cancer in men provides an overview of breast cancer in men breast cancer risk factors identifies and describes known risk factors for breast cancer breast health resources provides a listing for places and ways to find more information on breast cancer breast imaging methods explains the purpose and technical aspects of different breast imaging procedures breast reconstruction & prosthesis discuss reconstruction options, including the use of a breast prosthesis breast surgery presents types of breast cancer surgery and discusses the side effects from surgery carcinoma in situ defines carcinoma in situ (CIS) and describes appropriate treatments chemotherapy discusses all aspects of chemotherapy, including the types and side effects chemotherapy-coping with side effects describes side effects associated with chemotherapy, and discusses strategies for managing them clinical trials describes the process through which drugs and treatments enter clinical trials and how one joins a clinical research trial coping with a cancer diagnosis presents an overview of the emotional aspects of a breast cancer diagnosis current research on drugs & treatments discusses and describes new areas of drug and treatment research diet & nutrition during treatment provides important nutrition recommendations for breast cancer treatment and recovery ductal carcinoma in situ defines ductal carcinoma in situ (DCIS) and describes appropriate treatments follow-up describes the next steps to expect after breast cancer treatment is completed genetics & breast cancer explains the relationship between genetic mutations and the development of breast cancer 4
getting the support you need discusses how to get the social support you need healthy living discusses the importance of leading a healthy lifestyle hormone therapy describes hormone therapy and the various classes of drugs used how hormones affect breast cancer explains and discusses the association between hormones and breast cancer tumor growth if breast cancer returns physical and emotional issues related to the recurrence of breast cancer are addressed lymphedema discusses physical aspects of lymphedema making treatment decisions presents important steps to help you make treatment decisions mammography presents recommendations and the steps for getting this important breast cancer detection method medical vocabulary provides a guide to frequently used breast cancer terms new drugs for breast cancer treatment discusses new drugs being studied and those that are now available prognostic factors provides a guide to factors that determine a patient s chances for surviving breast cancer prophylactic mastectomy discusses issues and controversies about prophylactic mastectomy racial & ethnic differences describes differences in screening and detection between racial and ethnic groups radiation therapy discusses the aspects of radiation therapy, including the different types 5 radiation therapy-coping with side effects describes side effects associated with radiation therapy and discusses coping strategies sexuality & intimacy discusses issues related to sexuality and intimacy for breast cancer patients talking with your children discusses how to talk to your children about your diagnosis of breast cancer talking with your doctor describes how to communicate more effectively with health care providers talking with your partner discusses how to talk to your partner about your diagnosis of breast cancer tamoxifen discusses the use of tamoxifen as a hormone therapy treatment choices-an overview describes different treatments for breast cancer, along with tips for making treatment decisions types of breast cancer discusses the process of growth and the spread of breast cancer what is breast cancer? describes and explains the process of normal cells turning into cancer cells when the diagnosis is cancer-an overview provides an overview of the treatment process after diagnosis when you discover a lump presents an overview of what happens after a lump is found women who partner with women & lesbians presents breast health issues relevant to women who partner with women and lesbians young women & breast cancer provides an overview of breast cancer in young women