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e-Patient Scholarship Application
The Coalition for Compassionate Care of California (CCCC) is inviting e-Patients & Patient Advocates to apply for a special discounted rate to attend CCCC's 9th Annual Summit to be held in Sacramento, California, on March 13-14, 2017.

In total, the Summit features over 40 presenters representing a wide spectrum of palliative care topics including: community-based palliative care, quality metrics, payment models, public policy, pediatrics and other unique populations, and community engagement

Learn more about the Summit at http://ccccsummit.org.

Questions: Contact Keeta Scholl at kscholl@coalitionccc.org.

Scholarship Opportunity #1: Discounted Registration
All e-patients are invited to apply for discounted registration rates to the Annual Summit.

e-PATIENT EARLY REGISTRATION RATE: $249
Apply by 11:59 p.m., February 13, 2017

e-PATIENT LATE REGISTRATION RATE: $299
Apply online by 11:59 p.m., March 3, 2017

No discounts will be offered after March 3, 2017. If you would still like to attend the Summit at that time you must pay the full Summit registration rates, which can be found on this page: http://ccccsummit.org/registration.

e-Patient registration includes full access to all Summit sessions, breakout sessions, office hours, and breakfast and lunch on both days of the Summit. Travel and lodging are not included.

Scholarship Opportunity #2: E-Patient Scholar Program (includes all travel, registration fees, etc.)
This scholarship opportunity includes participation in the full e-Patient Scholar program and expectations as outlined previously. e-Patient Scholars will receive complementary registration, lodging/accommodations and travel to the Summit.

DEADLINE TO APPLY FOR E-PATIENT SCHOLAR PROGRAM: January 23, 2017

e-Patient Information
First Name
Your answer
Last Name
Your answer
Email Address
Your answer
Phone Number
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Twitter Handle
Your answer
LinkedIn Profile link
Your answer
Do you maintain a blog or a website?
If you have a blog or website, provide a link here:
Your answer
Essay questions
Tell us more about your experience as an e-patient.
How would you define what it means to be an “e-Patient?”
Your answer
Describe an experience you have had that has influenced your perspective on living with a serious or life-limiting diagnosis.
Your answer
How have you been involved in patient advocacy in the past, and what are you areas of interest for the future?
Your answer
Explain how your personal experience may connect with the purpose the CCCC Annual Palliative Care Summit.
Your answer
e-Patient Scholarships
Tell us which scholarship(s) you are applying for.
Are you applying for Scholarship #1: Discounted Summit registration?
Are you applying for Scholarship #2: E-Patient Scholar Program (includes all travel, registration fees, etc.)?
If you answered Yes to "partial scholarship" above, please elaborate on the type of financial assistance you need:
Your answer
Please describe your financial hardship...
Your answer
If applying for Scholarship #2, are you willing to share a room with another e-patient of the same gender identity?
With which gender do you identify?
Have you attended the CCCC Annual Palliative Care Summit in the past?
If yes, in which year did you attend?
If you have any special needs related to dietary restrictions or access requirements (pursuant to the ADA), please indicate them here:
Your answer
Our Promise to e-Patients
CCCC commits to creating a welcoming and comfortable environment in which e-Patients will receive the same level of respect and inclusion given to clinicians, researchers, policy makers and other Summit attendees.
The e-Patient Scholarship Program Includes
-- Full access to the 9th Annual Summit, including meals, cocktail hour, poster session and special evening session
-- Recognition of e-patients during the Summit program, in the Summit print materials, and on the CCCC website
-- Participation in two sessions for e-patients, including a prospective palliative care research project
-- (OPTIONAL) Ability to propose, develop, produce and showcase a professional poster during the palliative care poster session (mentoring will be included)
-- Discounted Summit registration and/or financial assistance for travel and lodging
-- Appreciation for the valuable perspective e-patients will bring to the palliative care conversation!
Expectations for e-Patient Scholars
On-going: Respond to surveys and requests for information in a timely fashion.

Prior to the Summit:
-- Participate in two (2) conference calls to plan and prepare for Summit-related sessions.
-- (OPTIONAL) Develop and produce a professional poster to be featured during the Summit poster session. Patients who wish to present a poster will receive mentoring from CCCC staff.

At the Summit:
-- Arrive at the Summit location for a special pre-Summit workshop from 5-7:30 p.m. on Sunday, March 12, 2017.
-- Attend the Summit in full, arriving on time and staying until the Summit ends on Tuesday afternoon, March 14, 2017.
-- Participate at the same level as all other Summit attendees by attending all general sessions and meet-ups, and by networking with others.
-- Participate in two (2) sessions specific to e-patients.
-- (OPTIONAL) Showcase a professional poster to be featured during the Summit poster session. Patients who wish to present a poster will receive mentoring from CCCC.
-- Tweet and post on social media using the Summit hashtag (#cccc17).

After the Summit:
-- Complete an evaluation related to your Summit experience.
-- Write a blog post about the Summit. The blog post can be posted on the e-patient’s personal blog (if available) or on CoalitionCCC.org.
-- Participate in a palliative care-themed tweet chat organized by CCCC within 2 months after the Summit. Exceptions can be made for participants who do not have access to Twitter.

How did you hear about this opportunity?
Your answer
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