UVM Cancer Center Membership Application (Non-Affiliate)

Membership Application Form

Questions with a * are required.
To apply for University of Vermont Cancer Center (UVMCC) membership, please submit the application below (note: you will be asked to upload your NIH biosketch at the end).

Contact Kate Webster, Executive Director of Administration by email at kate.webster@med.uvm.edu with questions. More information about UVMCC membership can be found here.

Please select the type of membership you are applying for: *

Trainee

New

Renewing

.

First Name *

Last Name *

Current Education Level *

Undergraduate Student

Medical Student

Graduate Student

Post-Doctoral Fellow

Academic/Professional Title *

Primary College (optional)

Department (optional)

Don't see the department you're looking for? Type it here:

Phone Number *

Email *

Demographics

Because increasing and enhancing diversity, equity, and inclusion is a specific focus of the NCI and UVMCC, we are collecting demographic information for our leadership and membership.

What is your ethnicity? *

Hispanic or Latino

Not Hispanic nor Latino

Prefer not to answer

What is your race? (check all that apply) *

If other, please specify (optional)

Do you identify as someone who has a disability? *

Yes

No

Prefer not to answer

Relevant Cancer Related Activities

Are you working on any collaborations with a current Cancer Center member? *

Yes

No

If yes, please list/describe the ongoing or current collaborations. *

Please include the name of the Cancer Center member you are working with: *

Please briefly describe your cancer related research, clinical research, or cancer care activities. *

Please briefly describe any community outreach activities. *

UVM Cancer Center Research Program Identification

Please indicate the UVMCC research program that you may feel is best aligned with your research and clinical expertise; each program area includes basic, clinical, and translational cancer research. For descriptions of programs, please refer to the UVMCC website research programs page.

*

Cancer Population Sciences (CPS)

Cancer Host and Environment (CHE)

Cancer Cell (CC)

Key Areas of Interest/Focus

Please indicate the areas of interest/focus that best align with your cancer research, clinical interest(s) and/or outreach/advocacy work. *

Fundamental Laboratory Research Areas

Population Science Research Areas

Translational Research and Clinical Trials

Disease-specific Interests

Translational Research and Clinical Trials

Clinical Trials Participation

Are you now, or have you previously been involved in clinical trials research? *

Yes

UVM Cancer Center Shared Resources/Technology

Indicate UVM Cancer Center Shared Resources that you currently utilize or plan to utilize.

Description of Research Activity

Provide a brief description of your cancer-related research/work, in lay terms. This information will appear on your Cancer Center profile page. *

Other titles, distinctions, and appointments (e.g. academic awards, named professorships, academic distinctions, fellowships, etc.)

Upload your NIH Biosketch.

If applicable, upload other support pages (other sources of external support for your research).

Upload your headshot (optional).

Key areas of interest/focus (choose all that apply): *

Laboratory research

Population health and behavioral research

Clinical research

Are you interested in the Summer Student Research Fellowships in Cancer Research Program? *

Yes

No

Are you interested in speaking with a Cancer Center member who could serve as a mentor? *

Yes

No