Trainee Membership Application

Eligibility Requirements:

Current undergraduate, graduate, predoc, postdoc, clinical fellow, or resident
Interest in cancer related disciplines
Participant in cancer training programs/activities
Ability and willingness to contribute to the cancer center programs and activities.

Membership Privileges:

Access to connect with various JCCC research programs and extended cancer center network
Access to grant writing support workshops
Access to training opportunities
Access to career development opportunities
Access to internal and external funding opportunities
Access to support for cancer related activities and events
Access to attend/participate in other UCLA, state and national level education and training activities Inclusion in JCCC communications, meetings, retreats, symposiums, seminars and other events
Lunches with distinguished speakers
Opportunity for upcoming Travel Awards Program
Opportunity to become a Trainee Ambassador

Trainee Category

If other please fill in below

Are you currently a UCLA trainee?

Yes
No

If no, please fill in what school, college, or university you belong to.

Trainee Information

Please complete the following contact information. If no middle name, put N/A. If you are not a UCLA student, put N/A in the UID number.

First Name

Middle Name

Last Name

UID (UCLA ID Number)

University Email Address

Personal Email Address

Primary Department/ Division/ School

If other please fill in below

Which cancer center program best fits your primary area of interest?

The Cancer Center currently operates six research programs:

Cancer research program

If your interests lie outside of the defined programs, please describe your cancer-related activities briefly below and we will assign you a research program?

Expected Graduation Date (if you are a graduate what was your last graduation date)

(DD/MM/YYYY)

Please add your social media links: Linked In Profile (URL link), Twitter profile (URL link) etc.
If not applicable or prefer not to share, please write N/A

Demographic Information

The following demographic sections are optional. Your response will be kept strictly confidential and demographic data for our JCCC trainee membership will only ever be reported in aggregate. We ask for this information in an effort to better understand our membership and better enable our Center to live up to its commitment of promoting equity, diversity and inclusion across all of our activities.

Please indicate the gender you identify with:

Male
Female
Transgender Female
Transgender Male
Non-binary/ Non-conforming
Prefer to self identify (Please fill in below)
Prefer not to respond

Please indicate the race/ethnicity you identify with:
Select all that apply

American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino/Latina/Latinx
Native Hawaiian or Pacific Islander
White
Prefer to self identify (Please fill in below)
Prefer not to respond

Which country and/or state do you originate from?

Mentor Information

Primary Mentors First Name

Primary Mentors Last Name

Primary Mentors Email Address

Secondary Mentor Information

If not applicable please write N/A

Secondary Mentors First Name

Secondary Mentors Last Name

Secondary Mentors Email Address

Scientific Information
If not applicable please write N/A

ORCHID ID

Trainee Positions, Scientific Appointments, and Honors

Awards (Fellowship Awards, K Awards etc.)

Trainee Cancer Related Publications

Please share any additional information you feel is relevant. (clubs, programs, affiliations, or success stories)

Trainee Membership Application

Eligibility Requirements:

Membership Privileges:

Degrees Attained