Consortium Membership Application

Consortium Membership Application

See criteria for membership: https://www.cancerconsortium.org/membership.html

First Name*

Middle Initial

Last Name*

Degree(s)*

Email*

ORCID (Digital Identifier)*

If you do not already have an ORCID, please register for one at https://orcid.org/

Primary Institution*

Fred Hutch

Seattle Children's

University of Washington

Secondary Institution(s)

Fred Hutch

Seattle Children's

University of Washington

Fred Hutch Title (Research)

For example: Professor

Fred Hutch Title (Clinical)

For example: Physician

This may be in addition to or separate from your research appointment

Seattle Children's Title (Research)

For example: Principal Investigator

Seattle Children's Title (Clinical)

For example: Physician

This may be in addition to or separate from your research appointment

Seattle Children's Research Center

Ben Towne Center for Childhood Cancer Research

Center for Child Health, Behavior and Development

Center for Clinical and Translational Research

Center for Developmental Biology and Regenerative Medicine

Center for Global Infectious Disease Research

Center for Immunity and Immunotherapies

Center for Integrative Brain Research

Seattle Children's Academic Division (if applicable)

UW Title (Research/Academic)

For example: Professor

UW Title (Clinical)

For example: Physician

This may be in addition to or separate from your research appointment

UW Net ID

UW Department

Which best describes your professional role?*

Select all that apply.

Biostatistician

Clinical

Researcher

Will you be conducting interventional cancer-related trials with human subjects in the next 12 months?*

Examples may include cancer treatment trials for cancer patients; behavioral trials such as smoking cessation.

Yes

Are you a member of the Institute of Translational Health Sciences (ITHS)?*

Yes

Describe how your research interests are relevant to cancer:*

Describe ways in which you collaborate with other Consortium members:*

Provide examples of research grants, publications, clinical studies, etc.

Provide information about the cancer-focused study or trial for which you are either currently a PI or plan to open within the next 12 months.*

Other information or comments:

As a member, which Consortium benefits do you anticipate utilizing?*

Select all that apply.

Invitations to program retreats and/or Consortium-wide symposia

Subsidized rates on Shared Resources

Eligibility to apply for CCSG developmental funds and/or administrative supplement funds

Use of Clinical Research Support services and/or Institutional Review Board

Assistance in preparing large collaborative grants (e.g., NIH P01, P50, U01, U54 mechanisms)

Access to resources for community outreach and engagement; and/or education and training

All publications, press releases, or other documents that cite results from CCSG-supported research (including if resulting from the use of one or more Shared Resources) must include acknowledgement of the CCSG and maintain compliance with NIH Public Access Policy.

Recommended language:

This research was funded in part through the NIH/NCI Cancer Center Support Grant P30 CA015704.
This research was supported by the [insert name] Shared Resource of the Fred Hutch/University of Washington/Seattle Children's Cancer Consortium (P30 CA015704).