Become a Member – North Dakota Cancer Coalition

Interested in the North Dakota Cancer Coalition?

Complete the form below to become a member and receive NDCC communications. Please make sure to select your areas of interest from the list of priority topics. You can change your preferences at any time by going to any NDCC email and clicking “Update your preferences” or “Unsubscribe from this list” at the bottom.

Membership Form

First Name

Last Name

Organization Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Please indicate one or more workgroups or priority topics that you are interested in.

Action Teams and Priority Topics

The coalition needs your time and talent to work efficiently and effectively. Please indicate if you are interested in any of these committees.

Committees

Member Year

Membership Dues

Annual Membership ($50)

Waiver Request

Optional Donation

Tribute

Optionally, you may dedicate your donation to an individual or group.

Dedication

Dedicated To

Dedication Details

Dedication Photo

Choose File

Public

Make Public

Waiver Request

Complete this section if you are requesting to waive membership dues.

Reason for Waiver Request

Financial Hardship

Unemployment

Medical Expenses

Other

Reason for Waiver Request (Other)

By submitting this request, I certify that the information provided is accurate and that I am currently unable to pay the annual membership dues. I understand that the decision regarding my waiver request is at the discretion of the North Dakota Cancer Coalition and that all information will be kept confidential.

Payment Summary

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