Affiliate Scholar Application Form

Please provide the following information to apply for Affiliate Scholar membership. Applications will be processed on the first business day of each month.

Contact Information

First Name

Middle Initial

Last Name

Date of Birth

Email Address

Mobile Number

Check this box to receive text messages about program, funding, and job opportunities from the Cancer Center.

Academic Information

Institution Association **If you are a high school or middle school student, please select other and provide school name.

UC Davis

LLNL

Other…

Position Title

Primary Department (Optional)

Mentor

Yes

Your Degrees Achieved

Re-order	Degrees	Month	Year	Weight	Operations
	Degrees Degrees Enter other…	Month	Year	Item weight

more items

What type of degree are you pursuing now or intend to pursue next?

Research Area Interests

(Including relation to cancer)

Career Goal

Have you participated in a UCD Comprehensive Cancer Center workshop or program yet?

Yes

If yes, which event/s or program/s?

Have you participated in community outreach or fundraising for cancer research yet?

Yes

Please share why you would like to be affiliated with the Cancer Center.

Are you currently enrolled in an institutional training grant (e.g, T32, R25)?

Yes

Please upload your CV or biosketch

Maximum 2 files.
256 MB limit.
Allowed types: pdf, doc, docx.

Do not fill out this field