ACCC Membership::Institution/Group Practice Membership Application Form

Become a Cancer Program Member

This is a secure Web site. The information you enter here is encrypted. Please be assured that the Association of Community Cancer Centers does not sell the ACCC membership list or your personal information to any party.

Please complete and submit the form below to become an institution/group practice member of the Association of Community Cancer Centers. Once received, your application will be sent to the Membership Committee to be recommended to the Board for acceptance.

Once the application is approved, new member welcome packet will be sent to the designated Delegate Representative.

ACCC Cancer Program Membership Application

1. Applicant Information:
Institution/Group Practice:
Program (if different from above):
Address:
City:
State:
Zip:
Phone:
Fax:
Email:

2. Delegate Representative Information:
Name:
Degree:
Title:
Address (if different from above):
Phone:
Fax:
Email:

The Delegate Representative's responsibilities include: Distributing new membership cards within your organization Voting for Board of Trustees, and Nominating Committee positions Distributing notices of Bylaws addenda Distributing business meeting notices
3. Payment Details:
Our institution/group practice wishes to apply for ACCC membership. Please charge my credit card $1,045.00. We understand this constitutes our first-year dues once our application has been approved.
Payment by Credit Card:
Credit Card Number:
Credit Card Holder:
Expiration Date:

If you wish to pay by check, print this page and send it along with your payment to Association of Community Cancer Centers Membership Department, 11600 Nebel Street, Suite 201, Rockville, MD 20852.
Note: ACCC membership is established on a fiscal year basis (July 1 through June 30). New members who join on or after December 1 shall be charged at the rate of one-half the annual dues. The remaining half will be applied towards the following year's dues.

4. Indicate That Your Institution Meets the Following ACCC Membership Criteria:
Diagnose and/or treat a minimum of 100 patients per year
Have access to or participate in a Multidisciplinary Cancer Committee
Have at least one board-certified medical oncologist, radiation oncologist or surgeon
Have at least one oncology-certified nurse (OCN) or one who has been specifically trained in the care of patients with cancer
Provide oncology social work services (onsite or by referral)

5. Cancer Program or Group Practice Narrative Description:
Please include a short description of your institution or group practice (no more than 250 words):

6. Photograph or Logo of Your Institution/Group Practice:
A color photograph of your institution will appear on your online page on ACCC’s website. Please email the photo to membership@accc-cancer.org as an attachment. Acceptable formats: jpeg, gif, tiff, bmp, png, eps. Logos are accepted in lieu of a photo. (This is not mandatory for application submission but will enhance your institution’s online profile).

7. Hold Harmless Agreement:
“By submitting this application, the undersigned applicant agrees not to bring any action, suit, or proceeding or to assert any claim against ACCC or any of its members, officers, agents, or contractors, in law or in equity otherwise, relating to any decisions made in connection with this application or any action taken (or not taken) or any statement made in the course of their consideration of this application, and applicant expressly waives any rights it might otherwise have had to bring any such action, suit, proceeding, or to make any such claim.”
I Agree:
Institution Representative:

Lori Gardner, Senior Director, Membership and Marketing
Phone 301.984.9496, ext. 226, Email lgardner@accc-cancer.org