Survivor Advocate Application- Past Participant

Survivor Advocate Application- Past Participant

Please complete this application in its entirety, then e-mail/mail your application and supporting materials no later than Wednesday, December 30, 2015. Incomplete applications will not be considered for enrollment. Notifications of acceptance will be sent out by mid-January.

Advocates may only participate in the Scientist ↔ Survivor Program at an Annual Meeting twice. Thereafter, advocates may apply as an advocate mentor.

Part I - Applicant

Name:
Organization (if applicable):
Mailing address:
City /

State/Country

/

ZIP/Postal Code

Personal Phone :
Personal E-mail:

A. Advocate training and related experience.

1. Have you attendedadditional advocate training or mentorship programs in the last 3 years?

Yes No

If yes, please list the program(s) and year(s) you have attended:

Name: / Year:
Name: / Year:

2. Have you served as a cancer patient advocate on any grant or protocol review boards since participating in SSP?

Yes No

If yes, please list the program(s), review board(s) and year(s) you served:

Name: / Year:
Name: / Year:
Name: / Year:

B.Please provide an updatednarrative biographical sketch of 200–300 words.

1. What are your current advocacy priorities and plans for the coming year?(Please limit your response to no more than 200 words.)

D. Please indicate the organ site/focus you represent:

All Cancers / Kidney Cancer / Other respiratory system / Sarcoma & soft tissues
Brain Cancer / Leukemia/Lymphoma / Ovarian / Skin Cancer
Breast Cancer / Liver Cancer / Pancreatic Cancer / Stomach
Colon & Rectum Cancer / Lung & Bronchus Cancer / Pediatric Cancer / Thyroid Cancer
Gastrointestinal Cancer / Melanoma / Prostate Cancer / Uterine Cervix
Head and Neck Cancer / Multiple Myeloma / Reproductive Cancer / Uterine Corpus
Other

Part II – Organization

Organization:
Mailing address:
City /

State/Country

/

ZIP/Postal Code

Phone: / General Email:
Website: / Executive Director

3. What position do you hold within your organization? (If applicable, please check all that apply.)

Staff Officer Board Member Volunteer

Other
Years of Service:

4.What topics relative to this program would you like to receive more information about? Is there a subject that should be presented as a special interest session?

IMPORTANT

Advocates may only participate in the Scientist↔Survivor Program at an Annual Meeting twice.

Thereafter, advocates may apply as an advocate mentor (See advocate mentor application for details).

AACR will cover all travel and lodging for accepted participants during the program. However, participants are responsible for all incidental expenses including baggage fees, tips, poster costs, phone charges, laundry, meals outside the program, and rental cars.

All selected advocates will be presenting a poster in the general poster session. A title and poster description is required upon acceptance.

PLEASE NOTE

Applications are due Wednesday, December 30, 2015. Notifications of acceptance will be sent

by mid-January. After your materials are reviewed, you will be notifiedof the status of your application.

Please e-mail your application and supporting materials to:

Survivor and Patient Advocacy Program

American Association for Cancer Research

Phone: 215-446-7104, Fax: 215-446-7262

E-mail:

Thank you for completing this application!