Organization (Childhood Cancer) Membership Application

Please verify you are a non-profit with a primary interest in childhood cancer issues:*
To qualify for CAC2 membership as a Childhood Cancer Organization Member, an entity must be a nonprofit or coalition whose primary mission is focused on childhood cancer. If your non-profit or for-profit organization does not focus exclusively on childhood cancer, but you wish to support CAC2’s mission, we welcome your membership as a Supporting Organization. Please do not complete this application. Instead, please return to the Join page and complete the application for Supporting Organization Membership.
- YES
Begin the Membership Application Process
Your Organization's Name:
Membership Dues Level (Based on Annual Revenue):*
CAC2 Organization Membership annual dues are determined by the annual gross revenues during your most recent fiscal year (please consult Page 1 of your latest Form 990 or 990-PF).

About Your Organization
Organization Mailing Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
IRS Designation:*
Voting Representative:*
First Last
Please designate the one person who will serve as the Voting Representative and main point of contact for your organization.
Voting Representative Email:*
What is the best email to reach the Designated Voting Representative?
Voting Representative Cell Phone:*
What is the best phone number to reach the Designated Voting Representative?
Member Organization Profile
We will use the information in this section to populate your organization's profile on the CAC2 website.
Organization Logo File:
Max. file size: 64 MB.
Please upload an image file.
Mission:*
Describe your organization's mission.
Main Organization Phone:*
How can the public reach your organization by phone?
Executive Director:*

Who leads your organization?
Organization Website:*

If your organization doesn't have an online presence, please write N/A.
Geographic Footprint:*
Choose the geographical area most closely descriptive of the patient population your organization serves or the institutions your organization funds.
If you serve a region or a locality, please specify the geographical area.
Optional Focus Area Information: Please indicate the percentage(s) that best describes the focus your organization’s activities. Estimates are fine and should total to 100%
% Advocacy:
% Family Support:
% Survivorship:
% Research Funding:
% Other:
Other Focus
If Applicable
Optional Organization Information
CAC2 tracks the impact our members have in a variety of ways. Please help us by completing the following questions about your organization's reach and impact.
Annual Revenue:
Annual gross revenues from the organization’s most recent fiscal year (please consult Page 1 of your latest Form 990 or 990-PF). Please only list numbers here. If you need to make additional notes please use the Annual Revenue Notes field below.
Annual Revenue Notes
If Applicable
# of Families Impacted / Served:
# of Patients Impacted / Served:
# of Hospitals or Research Institutions Funded:
Number of Full Time Employees:
Number of Part-Time Employees:
Number of Volunteers:
Please provide an annual estimate.
Collaboration and Your Organization:
We like to celebrate and call attention to collaborative success. Please describe any collaborative effort(s) in which your organization participates in the pediatric cancer community – with other CAC2 members and/or outside of CAC2.
How did you learn about CAC2?
- Invitation to Join
- Internet Search
- Twitter
- Referral
- Media
- Facebook
- Event
- Other
Associate Members:
Organization Members can offer CAC2 membership to their staff and Board Members for no additional charge. Please designate associate members for your organization below, and CAC2 will add them under your account.
First Name Last Name Email

Your Contact Information
Are you the designated Voting Representative?
- Yes
- No
If yes, please skip the next three questions and choose a username and password. If no, please provide your name and contact information before choosing a username and password.
Name:
First Last
Email:
Phone:
Choose A Username:*
Enter A Password:*
Enter Password Confirm Password

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Billing Details
How do you want to pay for your membership?*
- Credit Card
- Pay By Check
Billing Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Credit Card
Card Details
Cardholder Name
Total
$0.00
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Admin Section
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Merge Membership Level

Welcome to the CAC2 Members Portal

Step 1 of 3

Begin the Membership Application Process

About Your Organization

Member Organization Profile

Optional Focus Area Information: Please indicate the percentage(s) that best describes the focus your organization’s activities. Estimates are fine and should total to 100%

Optional Organization Information

Your Contact Information

Billing Details

Admin Section

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First Name	Last Name	Email