All.Can Membership Application Form

1
In which capacity are you applying for All.Can membership?* This field is required.
Organisation member
Individual member
2
Personal Details* This field is required.
First Name
Last Name
Organisation
Please enter your email
Please enter your phone
3
Your Work in relation to All.Can* This field is required.Please give a short description of your work and how it is related to All.Can. Please describe your interest in All.Can, and how the goals and objectives of All.Can fit with your organisation’s goals.
Huge
Large
Normal
Small
Ok
Ok
4
Contribution to All.Can as Individual Member* This field is required.Please explain what added value you can bring to All.Can. What would be the purpose of joiing All.Can in the context of your professional activity? Also, please state areas you can contribute to (e.g. research projects to which you wish to contribute, events to co-host etc.)
Huge
Large
Normal
Small
Ok
Ok
5
About Your Organisation* This field is required.
Name of Organisation
Country Registered
Website URL
6
Type of Organisation* This field is required.
Patient advocacy organisation
Professional or scientific society
Cancer leagues
Academic institution
Private company
Healthcare payer and provider group
Other
7
Type of Organisation - Please Specify* This field is required.
8
Organisation Mission, Vision and Objectives* This field is required.When was your organisation established? Please describe your organisation's vision, mission and objectives:
Huge
Large
Normal
Small
Ok
Ok
9
Organisation Leadership* This field is required.Please add list of or link to overview of Board / Executive Committee Members (names, country, profession and/or affiliation - as applicable)
Huge
Large
Normal
Small
Ok
Ok
10
Statutes* This field is required.Please upload or provide link to your organisation's statutes / articles
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
11
Your Organisation's Work* This field is required.Please describe your organisation's work. Be sure to include your link with the cancer community and some examples of projects completed or in process. Please describe your interest in All.Can, and how the goals and objectives of All.Can fit with your organisation’s goals.
Huge
Large
Normal
Small
Ok
Ok
12
Geographical Scope* This field is required.Which countries, regions and continents does your organisation cover? All.Can International looks for members who not only have a national but international perspective and focus.
Huge
Large
Normal
Small
Ok
Ok
13
Funding* This field is required.How is your organisation funded? Who are your funders? Please list the names of those who fund your organisation.
Huge
Large
Normal
Small
Ok
Ok
14
Collaborative Projects* This field is required.Who do you currently partner with on projects and activities (other than your funders)? Please list some examples.
Huge
Large
Normal
Small
Ok
Ok
15
Area of Expertise* This field is required.What is your area of expertise (if any) in cancer policy?
Huge
Large
Normal
Small
Ok
Ok
16
Contribution to All.Can as Organisation Member* This field is required.Do you have the resources to take an active and constructive role in All.Can? If so, how would you contribute?
Huge
Large
Normal
Small
Ok
Ok
17
Do you have the ability to co-fund projects?* This field is required.
YESNO
18
Type of Membership* This field is required.
General member (not-for-profits)
Funding member (private sector)
19
Please tick All.Can Working Group(s) of interest to you* This field is required.
Research and Evidence
Public Affairs
National Initiatives
20
Conflicts of Interest* This field is required.Please state any potential conflicts of interest which we should be made aware of
Huge
Large
Normal
Small
Ok
Ok
21
Contact Details: Primary Contact* This field is required.Please list the names of leadership that can engage with All.Can as champions or ad hoc representatives in events or projects We ask that one person is nominated per organisation as primary contact.
First Name
Last Name
Title and position in organisation
Please enter your email
Please enter your phone
22
Contact Details: Secondary Contact* This field is required.Please list a secondary person in leadership that can engage with All.Can as champions or ad hoc representatives in events or projects.
First Name
Last Name
Title and position in organisation
Please enter your email
Please enter your phone
23
Contact Details: Additional ContactPlease list others in leadership that can engage with All.Can as champions or ad hoc representatives in events or projects.
First Name
Last Name
Title and position in organisation
Please enter your email
Please enter your phone
24
Contact Details: Submitter* This field is required.
First Name
Last Name
Please enter your email
Please enter your phone
25
Do you have any other Comments or Questions?
Huge
Large
Normal
Small
Ok
Ok
26
Please tick the box below to observe the Terms of Reference* This field is required.
I understand and observe All.Can's Terms of Reference
27
I DECLARE THE INFORMATION SUBMITTED ABOVE TO BE CORRECT AND ACCURATE* This field is required.
Clear
Should be Empty: