Applicant Information.

Transcription

1 Applicant Information. Please complete this application in its entirety. The application deadline is Tuesday, December 5, Applicants will be notified of their status by early-january. Please note, you cannot save your application online. Applications must be completed in one sitting. It is highly recommended to review the application questions in the pdf. document prior to completing the application. Incomplete applications will not be considered. * 1. Applicant Name Address Address 2 City/Town State/Province ZIP/Postal Code Country Address Phone Number * 2. Which year(s) did you participate in the Scientist<->Survivor Program? Year Year * 3. What is the focus of your current advocacy activity? Check all that apply. Advisory Patient Advocacy Patient Support Other (please specify) Political Advocacy Program Education Survivorship Research Advocacy 1

2 * 4. Please indicate the organ site/focus of your advocacy: Check all that apply. All cancers Brain cancer Breast cancer Colon & rectum cancer Gastrointestinal cancer Head & Neck cancer Kidney cancer Leukemia / Lymphoma Other (please specify) Liver cancer Lung & Bronchus cancer Melanoma Multiple Myeloma Ovarian cancer Pancreatic cancer Pediatric cancer Prostate cancer Reproductive cancer Sarcoma & Soft Tissue cancer Skin cancer Stomach cancer Thyroid cancer Uterine Cervix Uterine Corpus 2

3 General Advocacy Information * 5. Since attending the Scientist Survivor Program, have you attended other advocacy training/mentorship programs? Yes No If yes, please list the program(s) you have attended. * 6. Since attending the Scientist Survivor Program, have you served on any grants or review boards? Yes No If yes, please list the grant(s)/review board(s) you have attended. * 7. Please provide a detailed NARRATIVE biography describing your involvement in cancer-related advocacy. Please do not list your accomplishments. (If selected, your response will be included in program materials.) * 8. What are your current advocacy priorities and plans for the year 2018? 3

4 * 9. How do you think your participation at the AACR 2018 Annual Meeting will help you enhance your ability to serve your constituency? 10. Please list scientific topics of interest. Topic Topic Topic Topic 4

5 Advocate Poster Session Each accepted advocate must present a poster during the conference. Please provide the title of the poster along with one-word keywords that best describe your poster. * 11. Title of Poster * 12. Please provide a detailed description of your poster. The description should include information on your organizations mission, initiatives, programs and constituencies. (The description will be printed in the program book.) * 13. Are you applying as a representative of an organization? Yes No, I am applying as an Independent Advocate. 5

6 Organization * 14. What position do you currently hold within the organization? Founder Executive Director Staff Officer Board member Volunteer Other (please specify) * 15. Organization Organization Name Executive Director Address Address 2 City/Town State/Province ZIP/Postal Code Country Executive Director's Phone Number 16. Organization Website * 17. Please provide a brief description of the organization. Please limit your response to 250 words. 6

7 * 18. Briefly describe the organization's programs and services. Please limit your response to 250 words. 19. Approximate number of constituents served annually: 20. Briefly describe the constituents you serve. 7

8 Independent Advocate. * 21. Briefly describe the constituents you serve. * 22. How do you serve your constituencies? * 23. What programs and/or initiatives are you currently involved in? * 24. Have you been involved with any advocacy organizations? Yes No If yes, please list the organization(s). 8

9 Thank You for Completing This Application. Submitting this application DOES NOT confirm that you or your organization will be selected to participate in the Scientist Survivor Program at the AACR Annual Meeting The selection process is difficult as there are an allotted number of participants. Advocates may only participate in the Scientist Survivor Program at AACR Annual Meeting 2018 twice as an advocate. Once you have exhausted your opportunities, you may apply as an advocate mentor. 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. For additional information please contact: Survivor and Patient Advocacy Program American Association for Cancer Research Phone: Fax: ssprogram@aacr.org The AACR is thankful to its supporters of the Scientist Survivor Program. 9