CCAN Patient Voice Representative Application Form

First Name (required)

Last Name (required)

Address 1 Address 2

City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewanNorthwest TerritoriesYukonNunavut Postal Code

Phone (Daytime): Cell Phone or Other:

Your Email (required)

 I am a patient/survivor I am a family member/caregiver I currently work in cancer control and have an interest in cancer patient issues Other (please specify below) Specify if applicable

In what way are you connected to your cancer patient community? (select all that apply)
 I am not currently connected to a cancer patient community I am involved with a support and/or advocacy group at the grassroots level (please specify below) I am affiliated with a national cancer organization (please specify below) Other (please specify below) Specify other if applicable

What is it you would like to do as a member of the Patient Voice Network? (select all that apply)
 Speak to patient issues at a provincial or national level Serve as a patient advocate/representative at a committee or working group level Provide an informed patient perspective on issues relating to the patient community Serve in a leadership capacity on a national level Other: (please specify below) Other Patient Voice Network Objectives

Do you have skills and experience in the following areas? (select all that apply)
 Canadian health care system Media relations Project management Public speaking Policy development Management Presentation and Communication Research Advocacy Facilitation Committee/board involvement Other (please specify below) Other Volunteer Skills (if applicable):

Please tell us more about yourself, including your volunteer work or background as it relates to the cancer community.

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