Membership Application

Thank you for your interest in becoming a member of the South Carolina Cancer Registrars Association. Some SCCRA membership benefits are:

Access to the MEMBERS section of the SCCRA website.
Access to the online SCCRA Membership Directory.
Access to the SCCRA Facebook page.
Web-based opportunities.
Leadership and peer networking opportunities.
Discounted rate for the Annual Educational Conference.

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First Name *

Last Name *

Middle Initial

Credentials *

Birth Date (Month & Day) *

Month

Day

Year

Home Address *

Home Address2

City *

State *

Email *

Zip *

Home/Mobile Phone *

Please list your preferred number.

Job Title *

Employer *

Employer Address *

Employer City *

Employer State *

Employer Zip *

Business Phone *

Extension (if applicable)

Preferred Mailing Address *

Membership Classification & Dues *

Active/New ($30)

Associate/Sustaining ($15)

Student ($10)

Charter Member, N/A - Exempt from dues but requested to submit a completed membership form annually.

Membership dues must be paid before or on April 1st to receive the discounted rate for SCCRA Annual Educational Conference. On April 2nd and after all SCCRA membership renewals will be required to pay the
non-member registration fee for SCCRA Annual Educational Conferences.

If paying by check, please send payment to:

Delaine Jacobs (Treasurer)
11 Candlewood Lane
Columbia, SC 29209

Photo Release
I hereby grant permission to South Carolina Cancer Registrar Association to use photographs and/or video taken of me in publications, news releases, online, and in other communications related to the mission of South Carolina Cancer Registrars Association.

Photo Release Agreement *

Please select whether or not you agree with the above Photo Release statement.

Membership Application Disclosure
The South Carolina Cancer Registrars Association (SCCRA) collects Personal Information (i.e. name, address, contact information) that you voluntarily submit. This information is utilized for membership purposes only. We respect your right to privacy and will NOT share and/or sell this information with other entities, organizations, second/third parties, etc. No member or non-member of the SCCRA may use this information for any purpose other than education and association related business.

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