ESCAPE to Thrive 2018 Alum

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?*
What year(s) did you attend ESCAPE?*
  • ESCAPE Alum 2011
  • ESCAPE Alum 2012
  • ESCAPE Alum 2013
  • ESCAPE Alum 2014
  • ESCAPE Alum 2015
  • ESCAPE Alum 2016

There are 4 ways for alums to return to ESCAPE to Thrive:

 

1. Recruit two qualified newcomer advocates 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 are confirmed with payment of your $499 registration fee.

 

2. Recruit a new ESCAPE sponsor for $5,000+ and YOU are confirmed to attend (double occupancy). NO registration fee for you! (Contact sherri@escape4advocates.org if you want information on sponsorships.)

 

3. Opt to immediately confirm your space by paying in full to cover your stay at Miraval ($1,768.40 double occupancy or $2,273.72 single occupancy.) NO registration fee for you! (We’ll cover the costs for the conference portion for you.)

 

4. Complete this application and you will be added to the waitlist.  We will notify you if a spot opens up.

Which option are you planning to do?*

Additional Comments

Security Code

Share This Form

Powered by eTapestry.