California Ovarian Cancer Awareness Program Core Planning Group (CPG) Application

Thank you for your interest in COCAP's CPG. Before filling out this application, please take time to read the CPG Member Guidelines. Please complete the following application if you would like to contribute to COCAP's mission by being actively involved in the CPG. You will receive an e-mail confirmation once your application has been received by COCAP staff.

Thank you for your interest!

COCAP Core Planning Group Application

First Name Middle Initial Last Name Degree(s) Title Organization Address 1 Address 2 Address 3 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Phone Number Fax E-mail Address

Add me to the CDOC listserv to receive updates on cancer related issues in California.

Which category do you consider yourself?   Please Select..... Ovarian Cancer Survivor Ovarian Cancer Caregiver, family, or friend Researcher Healthcare Provider Academic Institution Representative Community Member Community Based Organization Member Other, please specify -->

Are you able to make the time commitment asked of all CPG members (monthly meetings held primarily through teleconference calls and 2-4 face-to-face meetings in the Sacramento area*)? *Travel expenses will be reimbursed Please select..... Yes, I will be able to make monthly meetings I will only be able to make some of the meetings (Please explain in Comments section below) My participation would be very limited (Please explain in Comments section below)

Please describe any resources you or your organization may be able to provide to help the CDOC mission (e.g. staff time, funding, educational materials, specific training or expertise, etc.).

Does the cancer-related work you/your organization do focus on a particular sub-population of California? If so, please specify (e.g. Korean-Americans, Latinos, under or uninsured populations, etc.)

What are you hoping to gain from your participation in COCAP CPG?

Additional Comments

* The California Dialogue on Cancer (CDOC) is a coalition of leaders in various areas of cancer control concerned with the burden on cancer on Californians.

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