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FISCAL YEAR 08 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 Ad Hoc Committees will you be participating in for FY08?

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.

To see what strategies work groups and committees are currently working on, please click - work group/committee strategies

To select your work group and/or 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 work groups and committees at any time.

UCAN WORK GROUPS
Evaluation	Membership	Advocacy	Disparities	Quality of Life

UCAN AD HOC COMMITTEES
UCAN Media/PR (new fy08)	Prostate	Colon	Breast/Cervical
Workplace (new fy08)	Clinical Trials	Skin	Ovarian

if you are not currently serving in a leadership role by either chairing a work group, a committee or sitting on the Executive Board, would you be interested in serving in a leadership role?*

YES

What resources, skills, and/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 for you in order to assist you and/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*

Fields marked with " * " are mandatory fields and you will not be allowed to submit the document until those are filled out.