2013 WCLC Advocacy Organization Travel Award Application

UPDATE: New deadline for applicants from Europe, South America and Asia is September 20, 2013

The International Association for the Study of Lung Cancer (IASLC) is seeking to award one more Advocacy Travel Awards to provide monetary help for a patient advocate from Europe, Asia or South America to attend the World Conference on Lung Cancer (WCLC) Oct. 27-30, 2013 in Sydney, Australia. The awardee will receive free conference registration, up to four nights’ accommodations, a free IASLC Membership 2014 and a cash award for 1,000 AUD. We ask that you please share this information with your networks, and anyone else who may be interested.

NOTE: Applicants for the award should be a lung cancer survivors with experience speaking about lung cancer, and in sufficient health for travel to Australia. IASLC members and non-members from Europe, Asia and South America are invited to apply.

Due to a short timeframe, we need all applications of interest by September 20^th, 2013 at the very latest. If you are interested, please complete the online application at:

This form is for both individuals and organizations to use for application. For more information about the awards, and to determine your eligibility for consideration, please read completely below. This award is for advocates only, and your application must demonstrate a history of working on behalf of patients and lung cancer advocacy. For information about scholarships to WCLC 2013, please visit http://wclc.iaslc.org/scientific-program/scholarships.html.

Program Description:

In its efforts to increase links to patient advocates and advocacy organizations around the world, IASLC will offer travel awards to a limited number of patient advocates to attend and participate in the World Conference. The number of travel awards shall be limited to a maximum of 5. Fewer than the maximum amount may be awarded, depending on the interest, qualification of the applicants, and the review process. Applicants for the Advocacy Travel Award will be required to submit a detailed application, a summary of expected outcomes for attending, and any other supporting documentation required for review by IASLC. In 2011, applications were limited to organizations that could show 501(c)(3) or similar type of non-profit status, but in 2013, individuals not affiliated with an advocacy organization may also apply.

Awardees will receive:

*Free Conference registration
*Cash Award in the amount of 1,000 AUD to help offset travel costs
*Up to 4 nights accommodation at one of the Conference contracted hotels
*Free IASLC Membership for 2014

Please note that if your travel costs exceed 1,000 AUD, the Conference will unfortunately not be able to provide further financial support. Any costs exceeding 1,000 AUD will be at your own expense.

If you have questions, please contact kristin.richeimer@iaslc.org.

Are you applying on behalf of an Advocacy Organization or are you applying as an Individual Advocate?

Your Full Name

First (Given) NameLast (Family) Name

E-mail

Confirm E-mail

Please tell us about you:

If you selected "Other", please include more information here:

IASLC Member ID (NOTE: Members and Non-members may apply. (Advocates may join as full voting IASLC Members for US$50.00.):

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

How long have you been involved in lung cancer advocacy?

Day Phone Number

Area CodePhone Number

Full Organization Name

Organization Website

Your Title within this Organization

Are you the only designated representative from your organization? If you select "no" or "unsure" your application may be rejected.

How many paid staff members do you have?

How many volunteer staff members do you have?

2012 Organizational Revenue (all amounts in US Dollars):

Upload 2011 IRS Form 990 now, or you must include other government verification of non-profit status and revenue/expense :

Upload a File

Upload web-sized Company Logo (if applicable) (.jpeg please, optional)

Upload a File

Please include your organization's mission statement here:

Are you a member of the Global Lung Cancer Coalition?

Are you likely to receive funds from any other source for attendance at WCLC 2013?

Have you worked on collaborative initiatives with IASLC in the past? (You will elaborate below.)

Please explain briefly why you would be unable to attend without financial assistance:

0/500

If you have worked with IASLC in the past, please describe those initiatives and how they were successful. If you have not worked with IASLC in the past, please describe several of you or your organization's most recent, major achievements (2-4 items):

0/500

Please use this area to describe the primary future initiatives you have identified for yourself or your organization (2-4 high priority items):

0/500

Please use this area to describe how attendance at the World Conference would benefit you or your organization and your efforts towards lung cancer advocacy:

0/500

Please describe your plan to share and disseminate information to the public about your attendance at the World Conference, the value of and science discussed the IASC World Conference on Lung Cancer, and raise awareness before, during, and after the WCLC This should be detailed, and specific, including a description of the audience (type and number) you believe could be influenced by your efforts.

0/500

Please use this area to describe how you or your organization and IASLC could partner in the future, including specific outcomes you would aim to achieve through this partnership:

0/500

Please include additional relevant information here:

0/500

IASLC WCLC 2013 Advocates/Advocacy Organization Travel Award Application

Section A: To be Completed by All Applicants (Individuals and Organizations)

Section B: For Organizations Only (Individuals, please skip to Section C below.)

Section C: To be Completed by All Applicants: Individuals and Organizations