2012 TELUS Reg Form

CBCF National Fellowship Competition 2012 TELUS-Canadian Breast Cancer Foundation Fellowship Competition

Registration Form

The Canadian Breast Cancer Foundation, in partnership with the Quebec Breast Cancer Foundation, is pleased to announce the launch of a new, one time funding opportunity: the TELUS-Canadian Breast Cancer Foundation Fellowship Competition.

The objective of this competition is to support the specialized medical and health professional training that will strengthen multidisciplinary care teams focused on improving breast cancer patient treatment and care across Canada. The Proposed Fellowship must show evidence of the ability to foster clinical/professional skills and/or theory and research skills for applicants in areas relevant to multidisciplinary breast cancer care. As a national one- time funding opportunity, funding will be awarded to applicants demonstrating the following criteria:

 Post-graduate level physicians and Advanced healthcare professionals in all disciplines relevant to multidisciplinary breast cancer care:

Physician Fellowships Medical /Surgical/Radiation Oncologists, Pathologists, and Radiologists who are registered in or have completed a Royal College of Physicians and Surgeons of Canada certified program or a College of Family Physicians certified program.

Advanced Healthcare Professional Fellowships Certified healthcare professionals seeking breast cancer research experience and/or breast cancer specialization including, but not limited to, Advanced Practice Nurses, Genetic Counselors, Social Workers, Pharmacists, and Psychologists.

 Fellowship proposals may involve:

 Clinical/professional training only

 Research only

 Both research and clinical/professional training

Preference will be given to Fellowship proposals that:

 Are a part of an established breast cancer research project with a translational and/or clinical component to be undertaken by the applicant; and/or

 Will provide skills and/or practical knowledge that the applicant will be able to use to strengthen a multidisciplinary breast cancer care team; and

Canadian Breast Cancer Foundation © 2012 Confidential 2012 TELUS-Canadian Breast Cancer Foundation Fellowship Competition 4  Provide compelling evidence that the applicant has a strong interest in and an ongoing commitment to breast health/breast cancer treatment and care, and intends to continue their career in Canada.

This Registration Form must be completed as the first part of an application for 2012 TELUS-Canadian Breast Cancer Foundation Fellowship Competition. The Fellowship Applicant for each proposal must submit a registration form, on or before the deadline of Thursday July 26, 2012. Only eligible projects will be invited to submit a full application.

Applicants may only register once and only the first registration will be accepted. Due to the nature of the review process, all registration and application materials must be completed in English.

It is the applicant’s responsibility to submit all required information and supporting documentation in the correct format. To ensure timely and thorough review of your submission, please follow these guidelines:

 Review the Canadian Breast Cancer Foundation National Fellowship Program Guidebook -Summer 2012 before completing this registration form.

 This Registration Form is the only acceptable format for submitting a registration.

 Note the character limitations for all input fields. Characters that are counted include: letters, symbols, numbers and punctuation. Spaces are NOT included in the count. The text of submissions beyond character limits will be truncated. Additional pages may NOT be added to the application to supplement input fields.

 All application documentation must be submitted electronically to [email protected]  This Registration Form must be submitted as a Word document (.doc/.docx).  All other attachments (i.e. proof of citizenship) must be submitted as either PDFs or Word documents (.pdf/.doc/.docx).  All files must use the naming convention: [surname]-[detail].doc/.docx/.pdf.

BY SUBMITTING THIS REGISTRATION FORM, APPLICANTS AND FELLOWSHIP SUPERVISIOR HAVE AGREED THAT THE GENERAL CONDITIONS AS OUTLINED IN THE Canadian Breast Cancer Foundation National Fellowship Program Guidebook-Summer 2012 APPLY TO ANY GRANT MADE PURSUANT TO THIS APPLICATION AND ARE HEREBY ACCEPTED BY THE APPLICANT(S) AND THE APPLICANTS’ EMPLOYING INSTITUTION

The Fellowship Applicant must be a Canadian citizen or permanent resident of Canada based in, or formally affiliated with, an eligible host organization (university, college, hospital, research institute or other qualified not-for-profit organization) in Canada and their primary professional practice must be within Canada.

The Fellowship Applicant will hold a Medical or professional specialty Degree. They do not need to have had formal research training. The Fellowship Applicant is the primary correspondent with the Foundation and is chiefly responsible for the work enabled by CBCF funding. Additional parties may not receive salary support as part of the project.

Proof of citizenship or permanent resident status must be provided as an attachment to this registration form. A scan of current passport, birth certificate or front and back of your permanent resident card may be provided.

Please refer to the Canadian Breast Cancer Foundation National Fellowship Program Guidebook- Summer 2012 for detailed information on the commitments and responsibilities of the Fellowship Applicant.

Basic Applicant Information Fellowship Prefix Given Last Applicant Name Name Title Mailing Address #, Street, Unit. City Province Country Postal Code Telephone # Ext. Fax # Email Citizenship Permanent Resident Status (if applicable) Professional Qualifications Highest Level of Qualification Achieved (provide designation, conferring institution and year awarded) Other Relevant Qualification Achieved (#2) Other Relevant Qualification Achieved (#3)

Proposed Fellowship title The title (100 words or less) must remain unchanged between the registration and the application. Proposal abstract Provide a concise (1,000 words or less) Lay Language summary of the training/ research project clearly describing. in plain English , the project context, objectives, methodologies, relevance and anticipated impact on improving team based multi-disciplinary breast cancer care. Please indicate whether this research is a part of an existing project.

Include in your narrative a description of how the study relates to the Foundation’s Mission and the Fellowship Programs Objectives and priorities, and the impact arising from this work. Also, please include information on how skills developed through the Fellowship will contribute to improving team care at the future site of practice, and future career plans post fellowship.

Applicants must indicate at least one (or at most two) Fellowship Supervisor(s), one of whom must be affiliated with the Fellowship Host Organization.

Fellowship supervisors are investigators or clinicians holding an academic appointment and involved in areas of investigation or professional practices with a clear and direct relevance to breast cancer and breast health. Fellowship supervisors who do not hold an academic appointment may be considered, providing they provide a brief outline of the training program, indicating the research/training facilities available and the organization through which the funds would be administered.

Supervisors are expected to provide input and guidance to the fellow regarding their application, and Detailed Project Proposal and to certify with their signature that they have consulted with the applicant and agree to supervise the fellowship.

Please refer to the Canadian Breast Cancer Foundation National Fellowship Program Guidebook- Summer 2012 for full details and requirements. Please provide the following information for the Fellowship Supervisor(s)*:

Fellowship Salutation Given Surname Supervisor #1 Name Title Department Affiliated Organization Mailing Address #, Street, Unit. City Prov./State Country Postal/Zip Code Telephone # Ext. Fax # Email

Optional Fellowship Salutation Given Surname Supervisor #2 Name Title Department Affiliated Organization Mailing Address #, Street, Unit. City Prov./State Country Postal/Zip Code Telephone # Ext. Fax # Email

*Supervisors must also complete the provided PROJECT TEAM MEMBER CERTIFICATION document and must be submitted with the registration package.

The Fellowship Applicant and Fellowship Supervisor/Mentor must EACH complete this Certification as part of a complete registration to the 2012 TELUS-Canadian Breast Cancer Foundation Fellowship Competition.

Surname Given Name Position Title

Organization Department

Street Address

City Province Postal Code

Telephone Number Fax Number E-mail Address

Project Team Member Role  Primary Applicant  Supervisor/Mentor I have commercial interests/conflict of interest, as defined in the Canadian Breast Cancer Foundation commercial interest/conflict of interest policy, to disclose:  NO  YES: Nature of commercial interest/conflict of interest. o Describe:

I hereby acknowledge my involvement as the Fellowship Applicant/Fellowship Supervisor/Mentor on this fellowship application. I hereby acknowledge that I have read the Canadian Breast Cancer Foundation Guidelines and hereby agree that if funded, I will abide by the terms, conditions, and obligations outlined therein, and the commitments described in this application. I further agree and certify that the statements contained in this application are true, complete, and accurate to the best of my knowledge. I consent to the collection, use, and disclosure of information contained in this application as described in the guidelines referenced above. I have read the formatting and content requirements and understand that if my application does not meet the requirements, it will be rejected.

Signature ______

Date ______

Witness______

Date______