NCUK AMBASSADOR APPLICATION FORM
Personal Information
Title
Please select...
Mr
Mrs
Miss
Ms
Dr
Professor
Other / Prefer not to say
First Name
Surname
Email
Telephone Number
Address
City
County
Post Code
Country
Please select...
England
Northern Ireland
Scotland
Wales
About you
Are you a:
Please select...
Patient
Supporter
Other
If selected other, please specify:
If you are a patient, where is your Neuroendocrine Cancer primary site?
Please select...
ACC (adrenocortical carcinoma)
Appendix
Breast
Bowel - Large bowel (colon)
Bowel - Small bowel ( jejunal, Ileal or caecal)
Duodenal
Gastric (stomach)
Goblet cell carcinoma
Gynae (cervical, uterine, ovarian, vaginal or vulval)
Liver
Lung
MEN (multiple endocrine neoplasia)
Pancreas* (functioning or non-functioning)
Paraganglioma (extra-adrenal phaeochromocytoma)
Phaeochromocytoma
Prostate
Rectal
Skin (merkel cell carcinoma)
Testicular
Thyroid (medullary thyroid carcinoma)
Unknown primary
Secondary site
Please select...
Bone
Breast
Liver
Lung
Lymph nodes
Pancreas
Skin (not Merkel Cell carcinoma)
Experience
Please write your skills and experience in relation to patient advocacy:
Why would you like to become an NCUK Ambassador?
Keeping in Touch
Your support is vital and we’d love to keep you posted with our news, activities and appeals. Your details will only be used by the Neuroendocrine Cancer UK – we will
never
give your information to other organisations to use for their own purposes. You are free to change your mind at any time. Please tell us if you would be happy for us to contact you:
I give my permission to be contacted by the NCUK regarding my application
I would like to receive newsletters and updates
I do NOT want to receive newsletters or updates
How did you hear about us?
GP
Leaflet etc.
Nurse or hospital team
Other charitable organisation
Social media
Website search
Word of mouth
Other
Contact Information