Patient/Survivor/Caregiver Membership Application

Patient/Survivor/Caregiver Membership Application

Please complete the secure form and you will receive a confirmation. Or, you can print and mail/fax form to: IASLC Member Registration, 13100 East Colfax Ave., Unit 10, Aurora, Colorado 80011, USA. Fax: 720.505.2176
IASLC has launched a new free membership for all patients/survivors of any thoracic malignancy, and for caregivers providing service and care to loved ones affected by thoracic malignancies.

All patients/survivors with a diagnosis of lung cancer, mesothelioma or other thoracic cancers and caregivers, qualify for the free membership. This non-voting membership can be renewed annually. Except for voting, the patient/survivor/caregiver membership includes all Allied Health Professional member benefits, and includes online access to the Journal of Thoracic Oncology, member meeting discounts, eligibility to apply for travel awards, and eligibility to serve on IASLC committees.

If individuals wish to have a voting membership, they can register HERE, and choose the Allied Health Membership for US$50. Please contact membership@iaslc.org with any questions.
Full Name*

First (Given) NameLast (Family) Name
Title*

Dr.Prof.Mr.Ms.Mrs.Other
Degrees (select all that apply)

MDPhDMD, PhDMBBSFRACPFRCPCMScRNLPNBSNFCCPMRCPMBABScFRCRPharmD
Other Degree(s) not listed above
I am:*

Patient/SurvivorCaregiverOther
Please tell us how you think the IASLC Membership will benefit you:
Please feel free to tell us about your story with lung cancer (disease, stage, age at diagnosis, years living with cancer, etc.) - This is NOT required, only if you wish to share:
Please select Renewal or New Member:*
If renewing, please enter IASLC Member ID (if known):
E-mail*
Confirm E-mail*
Telephone*
Gender*

MaleFemale
Birth Date*

DayMonthYear
Institution/Organization Name (enter "n/a" if you are unaffiliated)
Your Professional/Academic Title
Department/Division Name
Address (this will be used for all IASLC postal correspondence):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Specialty*
Secondary Specialty
Additional Specialty
Include Other Specialties Not Listed Above
IASLC has an online and printed directory. Would you like to be included in the printed directory? *
Would you like to receive the printed membership directory in 2017?*
Would you like to receive complementary access to online JTO subscriptions:

YesNo
By typing my full name, I attest that the information entered here is true and correct.*
Name

First NameLast Name
Should be Empty: