Membership Registration Form

Membership *

NewRenewal

Today's Date *

Credentials *

Choose credentials you haveCTRRHITRHIAOther

Other Insert other credentials you have

Full Name *Enter First and Last name

Preferred Email *This will be the email used to notify you of any updates from CRAAZ.

Address *

HomeWork

Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Preferred Telephone # *

HomeWorkCell

Phone *Enter contact phone number you can be reached at.

Membership Categories/Annual Dues *

Choose a category that fits your membership.Active ($25.00): Primary occupation cancer registry work (abstracting, follow up or supervision). Can vote, hold office and/or chair committee.Associate ($15.00): Person interested in purpose of association. Primary occupation CANNOT be cancer registry, cannot vote, hold office or chair committee.Student ($10.00): Person enrolled in college level curriculum courses pertaining to medical records or cancer registry. Cannot vote, hold office or chair committee.Inactive ($15.00) An inactive member is no longer working within the cancer registry field. This category includes retirees, unemployed persons, and persons on extended leave from their cancer registry position. An inactive member shall not vote, hold office or chair a committee, but may serve on a committee.Sustaining ($50.00) – Person, institution or organization interested in promoting purpose of CRAAZ. Cannot vote, hold office, or chair a committee.

Name of College and Program

Would you be willing to serve on a committee? *

YesNoMaybe

What topics are you interested in for future CRAAZ education activities?

Membership Registration Form

Thanks for being a CRAAZ member for 2021

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