Membership Application Form

Membership Application Form
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MEMBERS' AREA

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Membership is free and open to all health care professionals with an interest in primary care cancer research.

A function of the Members Database is to act as a search tool to assist members identify potential collaborators or expertise, and allow contact to be made.

If you do not wish to participate in this service, simply tick the box and your form will not be available for viewing.

YOUR DETAILS

Title*

First Name*

Last Name*

Institution*

Department*

Suburb*

State*

Postal Code*

Region*

Country*

Email*

Telephone

Mobile

Fax

* Compulsory fields

DISCIPLINE

GP Medical Oncology Nursing Occupational Therapy Physiotherapy Psychology Radiation Oncology Social Work Surgeon Dietetics Speech Pathology Psychiatry Other - specify

Other Discipline

YOUR ROLE

Academic Clinician (exclusively) Data Manager Health Care Manager Project or Policy Role Research Officer Other Medical Professional - specify Other - specify

Other Role

YOUR RESEARCH INTEREST(S)

What are your area(s) of research interest? Tick as many as you like.

CANCER SITE

All Brain Breast Gynaecological Haematology Head and Neck Leukaemia Lower GI Lung Lymphoma Prostate Sarcoma Skin and Melanoma Upper GI Urological

Other Cancer

RESEARCH AREA

Prevention, Screening and Early Diagnosis Treatment, Shared Care and Survivorship End-of-Life-Care and Carer Support

Other research

MEMBERSHIPS

AGITG - Australasian Gastrointestinal Trials Group ASSG - Australasian Sarcoma Study Group ALLG - Australian Leukaemia and Lymphoma Group ANZBCTG - Australia New Zealand Breast Cancer Trials Group ANZCHOG - Australia New Zealand Childrens Haematology and Oncology Group ANZGOG - Australia New Zealand Gynaecological Oncology Group ANZMTG - Australia New Zealand Melanoma Trials Group ANZUP - Australia New Zealand Urogenital and Prostate Cancer Trials Group COGNO - Co-operative Trial Group for Neuro-Oncology PoCoG - Psycho-oncology Cooperative Research Group TROG - TransTasman Radiation Oncology Group CNSA - Cancer Nurses Society of Australia COSA - Clinical Oncological Society of Australia

Other Memberships

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