Cancer



Thank you for your interest 2015 ASCO Annual Meeting Conquer Cancer Foundation Patient Advocate Scholarship Program

The scholarship application period opens on Monday, April 6 at 12:00 PM (Noon) Eastern Time and closes on Thursday, April 9 at 12:00 PM (Noon) Eastern Time.

All applicants will be notified of their application status on April 14.

All patient advocates awarded a scholarship must register for the ASCO Annual Meeting at the patient advocate rate of $295 by the early registration deadline of April 22, 2015.

Please read the Scholarship Eligibility and Criteria before completing this application.

For questions or additional information, please contact patientadvocates@ or 571-483-1369.

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|First Name: |

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|Name of Organization (or research institution or committee) I will represent at the ASCO Annual Meeting: |

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|Mailing Address, City, State, Zip Code: |

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|Work Phone Number: |

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|Email Address (correspondence regarding scholarship will be sent to this address): |

1. Please briefly describe your financial circumstances and your need for a scholarship to attend the 2015 ASCO Annual Meeting (250 word count maximum).

2. Have you ever received a patient advocate scholarship from the Conquer Cancer Foundation to attend a past ASCO Annual Meeting or ASCO Symposia?

YES

NO

If YES, please indicate which meeting(s) and year(s) you received a scholarship: If YES, please briefly state how you have used the education you received as a result of attending the meeting(s) as a scholarship recipient (300 word count maximum).

3. Please list the advocacy organization(s) you are currently affiliated with and indicate your position and main responsibilities. Also indicate whether or not each organization is a not-for-profit, tax exempt organization. Also include any additional experience in research advocacy, public policy/legislative advocacy, and/or cancer patient support (300 word count maximum).

4. Will you be able to attend the entire 2015 ASCO Annual Meeting (the Meeting begins on Friday, May 29 at 1:00 PM and concludes at 1:00 PM on Tuesday, June 2, 2015)? For reference, the program is posted on the ASCO Annual Meeting website.

YES

NO (Please explain. 150 word count maximum)

5. If you are awarded a scholarship, do you agree to provide a brief testimonial (200 words or less) at the conclusion of the Meeting? (Testimonial will summarize your overall experience as well as the education you received from attending the ASCO Annual Meeting. Recipient must agree that the testimonial or a portion thereof may be posted on ASCO’s patient information website (), or on the Conquer Cancer Foundation website ()

YES

NO

6. Briefly state your expectations of the Meeting; what you intend to gain, how it will enhance your advocacy role(s) and your ability to serve people with cancer, and how you will share/disseminate what you learn (500 word count maximum).

7. Please upload your resume, bio-sketch, or curriculum vitae to accompany your application, in MS Word or Adobe pdf format (required).

For questions or concerns, please contact patientadvocates@ or 571-483-1369

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