FISCAL YEAR 10 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.

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

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

Yes

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

©Copyright 2009, Utah Cancer Action Network
Updated 10/21/2009
Disclaimer: Ucan.cc was created for the members of UCAN to share and find information on cancer activities in Utah. The website can also be used as a tool for the general public to find credible and evidence based resources related to cancer prevention, screening, treatment, and survivorship for some of the most commonly occurring cancers. This site is not a complete source for all cancer information.