2026 West Coast Conference Technology Assistance Program

Saving Your Application

We'd hate for you to lose your work on this application due to an unexpected internet outage or browser error, or because you had to step away before completing and submitting. The instructions below illustrate how to save your application as you go.

The first set of instructions is for saving on desktop or laptop computers, and the second set is for mobile phones and tablets. Be sure to read your relevant section in full before starting your application.

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Saving (on a desktop computer / laptop)

At the bottom of this page, you should see an icon that looks like this:
JotForm Save Icon

Clicking that icon will let you save your application.

A prompt will then ask you to login via Google or Facebook, or to "Sign up with Email." We recommend you instead click "Skip Create an Account." You will then enter your e-mail address and click "Send".

JotForm:

You will be emailed a link (unique to you) that you can click to return to your application at any point.

NOTE: When you return to your application, you will be taken back to the beginning. Look for green dots at the bottom of your screen and click to return to where you left off.

As you move through the application, a green arrow will show on top of the save icon to confirm your work is being saved. It will look like this:

JotForm - Save Confirmation

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Saving (on a mobile phone / tablet)

At the bottom of this page, you should see an icon that looks like this:

Clicking that icon will let you take you to the following page. Clicking the circled icon will let you save your application.

JotForm - Press Mobile Save

A prompt will then ask you to login via Google or Facebook, or to "Sign up with Email." We recommend you instead click "Skip Create an Account." You will then enter your e-mail address and click "Send".

You will be emailed a link (unique to you) that you can click to return to your application at any point.

NOTE: When you return to your application, you will be taken back to the beginning. Look for green dots at the bottom of your screen and click to return to where you left off.

Terms and Conditions* This field is required.Please review and accept the following to proceed.

Name* This field is required.

First Name

Last Name

Email* This field is required.

example@example.com

Phone Number* This field is required.

Please enter a valid phone number.

Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

Date of Birth (MM/DD/YYYY)* This field is required.

I am a:* This field is required.Please note: This program is only open to patients and survivors diagnosed with cancer.

Patient/Survivor

Patient/Survivor AND a healthcare professional (nurse, social worker, navigator, doctor, etc.)

Patient/Survivor AND a nonprofit professional

Healthcare professional ONLY (nurse, social worker, navigator, doctor, etc.)

Nonprofit professional ONLY

Other

I am:* This field is required.Please note: This program is only open to patients and survivors diagnosed with cancer.

Just diagnosed, pre-treatment

In-treatment (1 year or less)

In-treatment (1 year - 3 years)

In-treatment (3 years - 5 years)

In-treatment (5 years or more)

Post-treatment (5 years or less)

Post-treatment (5 years or more)

Not diagnosed

Are you currently pursuing a degree full or part time?For example: Associates, Bachelors, Masters, etc.

YESNO

Cancer Diagnosis (select all that apply)* This field is required.

Bladder

Blood (leukemia, lymphoma, multiple myeloma)

Breast

Colorectal (colon, bowel, rectal)

Endocrine (thyroid,parathyroid, pituitary, islet cell, adrenocortical carcinoma)

Eye (retinoblastoma,intraocular melanoma)

Gastrointestinal (esophagus, stomach, liver, gallbladder, pancreas, GIST)

Gynecologic (ovarian, uterine, vaginal, vulvar, fallopian tube, cervical, endometrial, gestational)

Head and Neck (laryngeal, lip & oral cavity, mouth, throat, pharyngeal, sinus & nasalcavity)

Kidney

Musculoskeletal (bone, soft tissue sarcoma, Ewing sarcoma)

Neurologic (brain, neuroblastoma, spinal cord)

Penile, prostate, testicular

Respiratory (lung, mesothelioma, thymoma, thymic carcinoma)

Skin (melanoma,Kaposi sarcoma)

Unknown origin

Other

Which of the following best describes you?* This field is required.

Woman

Man

Non-binary

Agender

Gender fluid

I don't know/I am not sure

Prefer not to answer

Other

Are you transgender?* This field is required.

Yes

Prefer not to answer

What are your pronouns?* This field is required.

She/Her

He/Him

They/Them

Ze/Zir

Ze/Hir

Prefer not to answer

Other

Are you Hispanic, Latine, or Spanish descent?* This field is required.

Yes

I don't know

Prefer not to answer

Which of the following best describes your race / ethnicity? (select all that apply)* This field is required.

Asian or Asian American

Black or African American

Hispanic, Latine, or Spanish origin

Middle Eastern or North African

Native American or Alaska Native

Native Hawaiian or Other Pacific Islander

White Non-Hispanic

Prefer not to answer

Don't Know

Other

Do you speak any languages besides English fluently?* This field is required.

Prefer not to answer

Other

Have you ever served in the U.S. military or military reserves?* This field is required.

Yes

Prefer not to answer

Please choose the option(s) that best reflect your ability status. We are interested in this identification regardless of whether you typically request accommodations. (select all that apply)* This field is required.I describe myself as a person:

With vision loss/low vision or who is blind

Who is hard of hearing or deaf

Who uses a wheelchair, crutch, or other assistive mobility device

With a brain injury or other acquired cognitive disability

A disability not listed above

I do not identify as a person with a disability

Prefer not to answer

Other

Employment Status* This field is required.

Employed full-time

Employed part-time

Self-employed

Employed full-time but looking for a new job

Employed part-time but looking for a new job

Unemployed, looking for full-time work

Unemployed, looking for part-time work

Neither employed nor looking for work

Retired

Current or Former Job:

How would being granted a 2026 West Coast Conference Technology Assistance Program award make a difference in your life and work circumstances right now?* This field is required.For example: could having better access to technology help you with work, remote work, a job search, telehealth doctor visits, etc.? If you currently have an older device, borrowed device or only have a device provided by your workplace, how could a new one benefit you?

Do you have access to any of the below at home? (select all the apply)* This field is required.Please use the "Other" field below to provide any important additional context, such as if your devices are employer-owned, or borrowed / not directly owned by you.

Desktop computer

Laptop, notebook or Chromebook (any brand)

Tablet (a portable computer with touchscreen, such as iPad or Amazon Fire)

Smartphone

Do not have this kind of technology at home

Other

Do you have internet access in your home? (select all that apply)* This field is required.If you do NOT have internet access in your home, please use the "No" field below to let us if you use any alternate method for accessing the internet, such as a library, community center, or someone else's home.

Yes, through an internet provider

Yes, through data on a smartphone or tablet

Other

Are you able to access the internet to attend the West Coast Conference on Work and Cancer on Saturday, October 17, 2026 from 9:00 AM - 4:00 PM (Pactific Time)?* This field is required.Please note: All award recipients are expected to attend the entire conference. However, please contact us directly if this poses an undue hardship (such as work or treatment schedules).

YESNO

What is your current work situation, and how has cancer impacted your job and/or work path?* This field is required.For example: What kind of job do you have? Are you looking for work, and if so, what kind of work are you looking for? Has taking time off for treatment put you behind at work? Because of side effects, do you need to shift to a job that requires new skills? Has your cancer experience made you realize that you want to find more meaningful work in a different company or industry? (NOTE: You will be asked to discuss financial circumstances in a follow-up question.)

How will the information presented at the West Coast Conference help you address some of the issues that you identified in the previous question?* This field is required.For example, how will attending this conference make a difference in your recovery or work? What work & cancer issue(s) do you wish you knew more about? For example: getting a new job; easing interactions with coworkers; understanding legal rights in the workplace; etc.? FYI: topics to be covered include balancing treatment and work, making disclosure decisions, job search, managing treatment side effects at work - and more! (The agenda is still being created.)

How many people are in your household including yourself?* This field is required.

In my household:* This field is required.

I am the only person in my home who provides financially

Other people in my home help financially

Other

Do you financially support anyone besides yourself?* This field is required.

Other

Are you currently responsible for paying off debt in any of these categories? (select all that apply)* This field is required.

Student

Mortgage

Credit Card

Medical

I am not paying off any debt

Other

Please provide any additional information on your financial circumstances that will help us understand your eligibility for this award.* This field is required.Things you may want to include (though not required): annual household income, financial burdens, extenuating circumstances, etc. We encourage you to provide as much insight as you are comfortable with to help us best understand your current situation.

Is there anything else you would like us to consider as we review your application?

How do you prefer to be contacted if you are chosen to receive an award?* This field is required.

Phone

No preference

How did you hear about the West Coast Conference Technology Assistance Program? (select all that apply)* This field is required.

Healthcare professional (e.g. social worker, nurse, financial navigator, etc.)

Support Group

Friend / family member

Other cancer community organization

Cancer and Careers website

Cancer and Careers email

Cancer and Careers social media post (on Twitter, Facebook, Instagram, LinkedIn)

Cancer and Careers presentation / workshop / event

Social media post from another person or organization

Other

Have you previously used any of the following Cancer and Careers programs or resources? (select all that apply)* This field is required.

Website

Balancing Work & Cancer Webinars

Virtual Conferences (National, Midwest, West Coast)

In-Person Conferences (New York, Chicago, Los Angeles)

Publications

Resume Review Service

Financial Assistance Grants

Job Search Intensive

Community Events

Technology Assistance Program

None

Other

Signature

By signing your full name on the following page, you agree to the following statements:

I have read and understand the Terms & Conditions.
The information I provided on this application is complete, accurate and truthful.
If chosen as an award recipient, I will attend the 2026 West Coast Conference on Work and Cancer held online on Saturday, October 17, 2026, from 9:00 AM - 4:00 PM (PT).
I am at least 18 years of age, residing in the U.S.
If chosen as a recipient, I will participate in follow-up surveys.

Signature.Use your mouse curser (if on a desktop computer / laptop) or finger (if using a mobile phone or tablet) to sign your full name in the box below. IMPORTANT NOTE: Then be sure to click "Submit" in the orange bar at the bottom to complete your application.

We're sorry. This program is only available to patients/survivors who have been diagnosed with cancer and are not actively pursuing a degree (Associates, Bachelors, Masters, etc.).

Applications received from anyone who has not received a diagnosis, or who is in school for a degree are not be eligible for consideration.

If you are a healthcare, nonprofit and/or HR professional interested in our other programs, opportunities for accreditation or additional grants and resources, please feel free to email Rachel Becker, LMSW Deputy Director, at rbecker@cew.org.

2026 West Coast Conference Technology Assistance Program - Application