Membership Form

 Group: Licensed physicians and allied health professionals including but not limited to registered nurses,
nurse practitioners, clinical nurse specialists, pharmacists, physician assistants, administrators, social
workers, and office managers in an oncology practice or university. Dues: Up to 10 physicians $750
(Small), 11-25 physicians $1,000 (Medium), 26+ physicians $1,500 (Large). All affiliated
allied health professionals are complimentary.
Select your organization from the list of existing Groups. If your organization is listed, your Group
administrator will cover the dues indicated above. If your organization is not listed, select the option
to start a new Group or select another type of membership. Fellows should always select the
“Fellow” type of membership even if their organization is listed below.
 Virginia Cancer Institute
 Start A New Group! (Be sure to provide your contact information on the next page!)
 Regular: Licensed physician caring for patients with cancer. Dues: $100.
 Allied Health Professional: Healthcare staff person including but not limited to registered nurse,
nurse practitioner, clinical nurse specialist, pharmacist, physician assistant, administrator, social
worker, and office manager. If affiliated with a Group, Dues: Complimentary. If not
affiliated with a Group, Dues: $50.
 Fellow: Physician enrolled in subspecialty training program to care for patients with cancer.
Dues: Complimentary.
 Retired: Former physician or