Member Organization Online Application

To apply for Alliance membership, please complete the below form. For questions, contact Heather Hirsch  Hirs0090@umn.edu or 612-624-4099.

  • The authorizer is an appropriate administrator within the organization who can authorize membership on behalf of the organization.
  • The primary contact will receive Minnesota Cancer Alliance communications and is responsible for disseminating this information to appropriate colleagues within the organization.
  • Use the attached forms to submit organization's primary and secondary contacts, communications contacts if applicable, and additional contacts for the Alliance mailing list.

The mission of the Minnesota Cancer Alliance is to reduce the burden of cancer for all persons living in Minnesota by working together to implement Cancer Plan Minnesota. Alliance members will:

  • Endorse the Minnesota Cancer Alliance mission
  • Agree to comply with Alliance organizational bylaws
  • Agree to be identified as an Alliance member in publications, lists, or other appropriate contexts
  • Agree to support and participate in Alliance evaluation efforts
  • Agree to designate one primary contact and one alternate contact to serve as a contact for Alliance communications within the organization.
PRIMARY CONTACT INFORMATION
Name 
Organization 
Title 
Street Address 
City 
State 
Zip Code  
Phone  
Fax 
Email 
Web Site 
ALTERNATE CONTACT INFORMATION
Name 
Organization 
Title 
Street Address 
City 
State 
Zip Code 
Phone  
Fax 
Email 
Web Site 
COMMUNICATIONS REPRESENTATIVE (if applicable)
Name 
Organization 
Title 
Street Address 
City 
State 
Zip Code 
Phone  
Fax 
E-mail 
Web Site