Cancer Patient Navigators of Georgia
GASCO Membership information
Patient Navigators
ASCO University

Membership Application

Click here for a printable version of this application,
or fill out the online application below.


There is no fee for joining Cancer Patient Navigators of Georgia in 2011; however, you must complete the application form in full.

Connect, educate, and share best practices
About You
Prefix
First Name
Initial
Last Name
Race
Age
 Gender
Your Employment
Organization / Institution Name
Title
Address
Address 2
City
County
State
Zip
Work Phone
Work Fax
Education
Education
 Credentials
Other
List Certifications
Other Training
Your Navigation

Navigation Program Setting
      
If other, please list:
 How many years have you served as a navigator?
Is your position...
Volunteer Paid 		Is your position...
Full Time Part Time
  
Navigation services YOU provide:
(check all that apply)
Screening
Diagnostic
Financial
Clinical
Resources
Psychosocial
Other:
Cancer Types in which YOU specialize
(check all that apply)
Breast
Lung
Colorectal
Ovarian/ Cervical
Prostate
 
Other:
Navigation Languages
(check all that apply)
English
Spanish
French
German
Chinese
 
Other:
Your Membership
Are you affiliated with a medical practice or organization which provides care to cancer patients in Georgia?
Yes No 		If you work under the direction of a physician who is a GASCO member, please indicate the doctor's name:
 
Member:Your work/title focuses completely on cancer patient navigation
Affiliate:You perform some aspects of cancer patient navigation as part of your role
Associate:You work, volunteer, or study in cancer control services and you are interested in cancer patient navigation
Honorary:You are a member of GASCO, GCC or Georgia CORE
Non-member:You are interested in getting information about this organization
Do you want to be Included in the Directory?
Yes No 		        Do you want to be included in the Listserv?
Yes No 		        Are you interested in working on a CPNG committee?
       
Email Address





The development of Cancer Patient Navigators of Georgia is supported by Gasco and GCC