Join UCAN

FISCAL YEAR 13 UCAN COMMITMENT FORM

First Name*

Last Name*

Title*

Organization*

Web Address

Mailing Address*

City*

State*

Zip*

Phone Number*

Cell Number

Fax Number*

E-mail Address*

Which UCAN Work Groups and/or Committees would you like to join?

UCAN members have various levels of participation. We encourage members to join a work group and/or ad hoc committee. These committees and work groups are charged with working on strategies identified in the state cancer plan. We ask that members only sign up for work groups and/or committees that they can participate in at least 50% of the meetings.

Click here for a description of the UCAN Implementation Teams.

To select your implementation team or ad hoc committee, simply check the one(s) you would like to join. If you don't want to join any, leave them blank. You can join, leave, and/or move between implementation teams and committees at any time.

UCAN Implementation Teams
	Advocacy & Public Policy
	Primary Prevention & Awareness
	Early Detection & Treatment
	Survivorship & Quality of Life
	Professional Education & Practice
	Data

UCAN AD HOC COMMITTEES
	Women's Cancers
	Colon Cancer
	Prostate Cancer
	Skin Cancer

Would you be interested in serving in a leadership role?*

Yes

No

What resources, skills, or educational opportunities can you contribute to UCAN in order to meet the goals, objectives, and strategies of the state cancer plan?

What resources, skills, and/or educational opportunities can UCAN provide you to assist you or your organization in meeting its goals and objectives?

Signature (type name)*

By signing this document, I understand that I am a participating member of the Utah Cancer Action Network and endorse the mission of the organization as outlined in the Utah State Cancer Plan.

Date*

*Mandatory fields required for submission

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