ESCAPE to Thrive 2018

If you are an ESCAPE alum there is a separate application for you.  

Click here! 

Contact Information

Country*
State / Province*
Address*
City*
*
*
*
*
*
*
Email*
Confirm Email*
Phone*
Organization Name
Position/Title in Organization
Organization Website
Age*

Advocacy Involvement (Check all that apply.)*
  • Cancer Trial/Research Reviews
  • Exercise Group
  • Legislative/Public Policy
  • Navigation
  • Patient Education
  • Retreats
  • Support Groups
  • Survivorship
  • Young Survivors
  • Other (explain below in additional comments section)
Are you a survivor?
  • Yes
  • No
If yes, cancer type

Target each response for the sections below to
approximately 500 words.

Please detail YOUR advocacy role:

(including dates, duration, nature of advocacy work, # people served, demographic)*

What population do you predominantly impact? (Check all that apply.)*
  • Children
  • General
  • Men
  • Rural
  • Seniors
  • Underserved/Minority
  • Women
  • Young Survivors
  • Other (explain below in additonal comments section)
What geographic region(s) do you reach?*
How do you envision the ESCAPE leadership conference being right for you?*
What do you hope to gain from the ESCAPE leadership conference?*
How did you learn about ESCAPE? (Check all that apply.)*
  • Alumnus
  • Conference
  • Email Blast
  • Facebook
  • Another Advocate
  • Search Engine
  • Twitter
  • Other (explain below in additional comments section)
If referred by an alum please enter name.
Anything else you want to tell us?

To receive a discount on your registration fee:
 
Recruit two qualified newcomer advocates (from different organizations) to apply to ESCAPE to Thrive. Once they have been accepted and have paid their $100 non-refundable deposit toward their $499 registration fee, YOU will receive a $50 discount on your registration fee.
Please include name, email & organization of each person.

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