Community Advocate Bio

Cancer Care Services is in the process of identifying potential members for a disparities and health equity coalition. Your input would be greatly appreciated.

Name

First NameLast Name

Email

example@example.com

Cell Number

Format: (000) 000-0000.

Have you been impacted by cancer? (Select all that apply):

List any skills or abilities you believe you can contribute to the community group:

List any connection to organizations or places within the community where members gather or where we may be able to gather information from community members:

Have you ever been involved in research? If so, what type? What was your role? Was that research relevant to this community?:

List any other groups within this community that you are part of:

Do you have any experience with the following?(Select all that apply):

Specific to the purpose of this community group, what do you see as your greatest contributions:

List any personal, social or political connections that you have within the community that may be an asset for this community group: