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

Your Organization's Tax Exempt Number (EIN)

Begin the Membership Application Process

Your Organization's Name:*

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 later in this process.

Membership Dues Level (Based on Last Form 990 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:*

Please designate the one person who will serve as the Voting Representative and main point of contact for your organization.

First Last

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:

Please upload an image file.

Max. file size: 80 MB.

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 leave blank.

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.