Chapter Leader Application
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FIRST STEPS

• Complete and submit the Chapter Application.
• All applicants will also be required to submit an application for a background check.  Background check clearance is a mandatory step in chapter activation.
• Once notified by ASHA of your acceptance, you will be required to submit an Annual Plan with your ideas and how you hope to accomplish them, including fundraisers and educational activities for your chapter in order to become an active chapter.

IN SHORT, HERE'S WHAT YOU CAN EXPECT ----
WHAT WE ASK OF CHAPTER LEADERS:

1. HAVE FUN!
2. Make a plan annually for what you hope to do to raise awareness of HPV and Cervical Cancer in your community.
3. Raise $100 (net) each year.
4. Stay in touch with Headquarters office.

WHAT ASHA/NCCC WILL DO FOR YOU AND THE CHAPTER:

1. Support you every way we can and provide you with all the tools you need to be successful, such as the NCCC logo, an official NCCC email, and business cards.
2. Handle all the legal requirements of being a non-profit including acknowledging donors for their contributions and managing state licensing for any of your activities.
3. Maintain all the financial and tax filings for any of your chapters.
4. And more!

NCCC CODE OF CONDUCT

NCCC Chapter leaders must adhere to the NCCC code of conduct. Violation of this code of conduct may result in immediate termination of a chapter leader's participation in the NCCC community as well as use of the website and any related services.

1. Always speak accurately and truthfully.
2. Always disclose your relationship with ASHA/NCCC and your participation in any NCCC program.
3. Never give medical advice or represent that you are giving medical advice. Make sure you communicate this to others. Inform others that you are sharing your personal opinion, thoughts, or experiences.
4. Always inform others that only physicians can prescribe medications or decide if a particular treatment option is right for them.
5. Always speak solely about the "on label" prescribed use of a drug.
6. Always allow others to form their own honest opinions based on information you have shared.
7. Always respect the privacy of others at all times. Never disclose their personally identifiable health information or other private information.
8. Never involve a child under the age of 18 in any ASHA/NCCC Program without direct participation of their parent or legal guardian.
Your name *
Street Address *
City *
State *
Zip *
County
Email *
Phone number *
Birthdate
What are you applying for? *
If you are applying to be a co-leader of an existing chapter, please note which chapter below.
How did you hear about ASHA/NCCC? *
What is your experience with HPV and cervical cancer?
Are you affiliated with any other health advocacy organizations? If yes, please describe your work/involvement.
What are your ideas for your chapter? *
How many people have you recruited or intend to recruit to assist you with the chapter? *
Are you willing to bring other people into your chapter who want to get involved in your area that ASHA/NCCC may refer to you? *
Required
Questions or comments?
I acknowledge that I have read the chapter leader application and accept the outlined responsibilities of a chapter leader and the NCCC Code of Conduct. *
Required
Signature *
(Type your complete name below)
Submit
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