Membership Application

The following are requirements for membership in the DCC. Each member organization agrees to:

Endorse and support the implementation of all DCC priorities;
Provide annual reports about progress and accomplishments;
Coordinate and collaborate within its own organization to implement strategies that address one or more DCC priorities; and/or
Coordinate and collaborate with one or more other organizations to implement strategies that address one or more DCC priorities.

I agree to comply with the above requirements.

Information about your Organization:

Organization Name:

Organization Website:

Phone Number:

Fax Number:

Mailing address:

Street:

Include any apartment or suite number, if applicable.

City:

State:

Zip Code:

Head of Organization:

The Director, CEO, etc...

Title/Credentials:

Organization Categorization:

Please review the organizational categories listed below. Choose the one category that best describes your organization, even if more than one category applies.

Network, cooperative or health care delivery system with cancer programs recognized by the American College of Surgeons
Health care/primary care delivery system or practice
Health care/primary care delivery system or practice
Health care purchaser
Public Health (local public health agency, e.g.)

Trade/professional organization
Health professional school or health research/evaluation/continuous quality improvement organization
Statewide or community-based organization representing specific populations including survivors, consumers, racial/ethnic groups, etc
Other

If other:

Representative Information:

Below, please provide the name of and contact information for your organization’s designated representative. Because the Consortium is an action-oriented body, it is important that you designate a senior representative with the authority to make decisions and commitments on behalf of your organization.

Representative's Full Name:

E-mail Address:

Phone Number:

Fax Number:

Mailing address:

Street:

Include any apartment or suite number, if applicable.

City:

State:

Zip Code:

Please upload your representative's Curriculum Vitae:

Interest in DCC Priorities:

Please check the priority/priorities that your organization will address and provide a brief description of your organization’s qualifications to address checked priorities.

Priority Area:

Description of Qualifications:

Delaware Cancer Registry Advisory Committee (DCRAC)

(cancer registry and registrars; data analysis, interpretation and technical assistance on cancer studies/reports; provides data expertise and technical knowledge to other committees)

Cancer Risk Reduction Committee (CRRC)

(tobacco use prevention; smoking cessation; lifestyle and risk reduction, translate data into information for public use, advocacy, link employers to DCC; healthy homes/occupational health)

Early Detection & Prevention (ED&P)

(lung, prostate, cervical/HPV, breast and colorectal cancer screening and early detection, translating data into educational information for public use)

Membership Application

Information about your Organization:

Mailing address:

Organization Categorization:

Representative Information:

Mailing address:

Interest in DCC Priorities:

Priority Area:

Description of Qualifications:

Delaware Cancer Registry Advisory Committee (DCRAC)

Cancer Risk Reduction Committee (CRRC)

Early Detection & Prevention (ED&P)

Additional comments or instructions?

Complete the application offline:

Cancers:

Prevention:

Programs:

Committees:

Resources:

Cancers:

Prevention:

Programs:

Programs: