CBCF National Fellowship Competition
2012 TELUS-Canadian Breast Cancer Foundation Fellowship Competition
Registration Form
The objective of this competition is to support the specialized medical and health professional training that will
strengthen multidisciplinary care teams focused on improving breast cancer patient treatment and care across
Canada. The Proposed Fellowship must show evidence of the ability to foster clinical/professional skills and/or
theory and research skills for applicants in areas relevant to multidisciplinary breast cancer care. As a national onetime funding opportunity, funding will be awarded to applicants demonstrating the following criteria:

Post-graduate level physicians and Advanced healthcare professionals in all disciplines relevant to
multidisciplinary breast cancer care:
Physician Fellowships
Medical /Surgical/Radiation Oncologists, Pathologists, and Radiologists who are registered in or have
completed a Royal College of Physicians and Surgeons of Canada certified program or a College of
Family Physicians certified program.
Advanced Healthcare Professional Fellowships
Certified healthcare professionals seeking breast cancer research experience and/or breast cancer
specialization including, but not limited to, Advanced Practice Nurses, Genetic Counselors, Social
Workers, Pharmacists, and Psychologists.

Fellowship proposals may involve:



Clinical/professional training only
Research only
Both research and clinical/professional training
Preference will be given to Fellowship proposals that:

Are a part of an established breast cancer research project with a translational and/or clinical component
to be undertaken by the applicant; and/or

Will provide skills and/or practical knowledge that the applicant will be able to use to strengthen a
multidisciplinary breast cancer care team; and

Provide compelling evidence that the applicant has a strong interest in and an ongoing commitment to
breast health/breast cancer treatment and care, and intends to continue their career in Canada.
Canadian Breast Cancer Foundation © 2012
Confidential
2012 TELUS-Canadian Breast Cancer Foundation Fellowship Competition
4
This Registration Form must be completed as the first part of an application for 2012 TELUS-Canadian Breast
Cancer Foundation Fellowship Competition. The Fellowship Applicant for each proposal must submit a registration
form, on or before the deadline of Thursday July 26, 2012. Only eligible projects will be invited to submit a full
application.
Applicants may only register once and only the first registration will be accepted. Due to the nature of the review
process, all registration and application materials must be completed in English.
It is the applicant’s responsibility to submit all required information and supporting documentation in the correct
format. To ensure timely and thorough review of your submission, please follow these guidelines:

Review the Canadian Breast Cancer Foundation National Fellowship Program Guidebook -Summer 2012
before completing this registration form.

This Registration Form is the only acceptable format for submitting a registration.

Note the character limitations for all input fields. Characters that are counted include: letters, symbols,
numbers and punctuation. Spaces are NOT included in the count. The text of submissions beyond
character limits will be truncated. Additional pages may NOT be added to the application to supplement
input fields.

All application documentation must be submitted electronically to nationalgrants@cbcf.org
 This Registration Form must be submitted as a Word document (.doc/.docx).
 All other attachments (i.e. proof of citizenship) must be submitted as either PDFs or Word documents
(.pdf/.doc/.docx).
 All files must use the naming convention: [surname]-[detail].doc/.docx/.pdf.
BY SUBMITTING THIS REGISTRATION FORM, APPLICANTS AND FELLOWSHIP SUPERVISIOR HAVE AGREED THAT
THE GENERAL CONDITIONS AS OUTLINED IN THE Canadian Breast Cancer Foundation National Fellowship
Program Guidebook-Summer 2012 APPLY TO ANY GRANT MADE PURSUANT TO THIS APPLICATION AND ARE
HEREBY ACCEPTED BY THE APPLICANT(S) AND THE APPLICANTS’ EMPLOYING INSTITUTION.
Canadian Breast Cancer Foundation © 2012
Confidential
2012 TELUS-Canadian Breast Cancer Foundation Fellowship Competition
4
1.
Fellowship Applicant Information
The Fellowship Applicant must be a Canadian citizen or permanent resident of Canada based in, or
formally affiliated with, an eligible host organization (university, college, hospital, research institute or
other qualified not-for-profit organization) in Canada and their primary professional practice must be
within Canada.
The Fellowship Applicant will hold a Medical or professional specialty Degree. They do not need to have
had formal research training. The Fellowship Applicant is the primary correspondent with the Foundation
and is chiefly responsible for the work enabled by CBCF funding. Additional parties may not receive salary
support as part of the project.
Proof of citizenship or permanent resident status must be provided as an attachment to this registration
form. A scan of current passport, birth certificate or front and back of your permanent resident card may
be provided.
Please refer to the Canadian Breast Cancer Foundation National Fellowship Program GuidebookSummer 2012 for detailed information on the commitments and responsibilities of the Fellowship
Applicant.
Basic Applicant Information
Fellowship
Applicant
Prefix
Given
Name
Last
Name
Title
Mailing Address
#, Street, Unit.
City
Province
Country
Telephone #
Postal Code
Ext.
Fax #
Email
Citizenship
Permanent
Resident Status
(if applicable)
Professional Qualifications
Highest Level of
Qualification Achieved
(provide designation,
conferring institution
and year awarded)
Other Relevant
Qualification Achieved
(#2)
Other Relevant
Qualification Achieved
(#3)
Canadian Breast Cancer Foundation © 2012
Confidential
2012 TELUS-Canadian Breast Cancer Foundation Fellowship Competition
4
2.
Proposed Project Information
Proposed Fellowship title
The title (100 words or less) must
remain unchanged between the
registration and the application.
Proposal abstract
Provide a concise (1,000
character) Lay Language
summary of the training/
research project clearly
describing. in plain English , the
project context, objectives,
methodologies, relevance and
anticipated impact on improving
team based multi-disciplinary
breast cancer care. Please
indicate whether this research is
a part of an existing project.
Include in your narrative a
description of how the study
relates to the Foundation’s
Mission and the Fellowship
Programs Objectives and
priorities, and the impact arising
from this work. Also, please
include information on how skills
developed through the
Fellowship will contribute to
improving team care at the
future site of practice, and future
career plans post fellowship.
Canadian Breast Cancer Foundation © 2012
Confidential
2012 TELUS-Canadian Breast Cancer Foundation Fellowship Competition
4
3.
Fellowship Supervisor
Applicants must indicate at least one (or at most two) Fellowship Supervisor(s), one of whom must be
affiliated with the Fellowship Host Organization.
Fellowship supervisors are investigators or clinicians holding an academic appointment and involved in
areas of investigation or professional practices with a clear and direct relevance to breast cancer and
breast health. Fellowship supervisors who do not hold an academic appointment may be considered,
providing they provide a brief outline of the training program, indicating the research/training facilities
available and the organization through which the funds would be administered.
Supervisors are expected to provide input and guidance to the fellow regarding their application, and
Detailed Project Proposal and to certify with their signature that they have consulted with the applicant
and agree to supervise the fellowship.
Please refer to the Canadian Breast Cancer Foundation National Fellowship Program GuidebookSummer 2012 for full details and requirements. Please provide the following information for the
Fellowship Supervisor(s)*:
Fellowship
Supervisor #1
Salutation
Given
Name
Surname
Title
Department
Affiliated
Organization
Mailing Address
#, Street, Unit.
City
Prov./State
Country
Telephone #
Postal/Zip Code
Ext.
Fax #
Email
Optional
Fellowship
Supervisor #2
Salutation
Given
Name
Surname
Title
Department
Affiliated
Organization
Mailing Address
#, Street, Unit.
City
Prov./State
Country
Telephone #
Postal/Zip Code
Ext.
Fax #
Email
*Supervisors must also complete the provided PROJECT TEAM MEMBER CERTIFICATION document and must be
submitted with the registration package.
Canadian Breast Cancer Foundation © 2012
Confidential
2012 TELUS-Canadian Breast Cancer Foundation Fellowship Competition
4
PROJECT TEAM MEMBER CERTIFICATION
The Fellowship Applicant and Fellowship Supervisor/Mentor must EACH complete this Certification as
part of a complete registration to the 2012 TELUS-Canadian Breast Cancer Foundation Fellowship
Competition.
Surname
Given Name
Organization
Position Title
Department
Street Address
City
Province
Postal Code
Telephone Number
Fax Number
E-mail Address
Project Team Member Role
 Primary Applicant
 Supervisor/Mentor
I have commercial interests/conflict of interest, as defined in the Canadian Breast Cancer Foundation
commercial interest/conflict of interest policy, to disclose:
 NO
 YES: Nature of commercial interest/conflict of interest.
o Describe:
I hereby acknowledge my involvement as the Fellowship Applicant/Fellowship Supervisor/Mentor on
this fellowship application. I hereby acknowledge that I have read the Canadian Breast Cancer
Foundation Guidelines and hereby agree that if funded, I will abide by the terms, conditions, and
obligations outlined therein, and the commitments described in this application. I further agree and
certify that the statements contained in this application are true, complete, and accurate to the best of
my knowledge. I consent to the collection, use, and disclosure of information contained in this
application as described in the guidelines referenced above. I have read the formatting and content
requirements and understand that if my application does not meet the requirements, it will be rejected.
Signature ________________________________________________________
Date ___________________________
Witness_________________________________________________________
Date_____________________________
Canadian Breast Cancer Foundation © 2012
Confidential
2012 TELUS-Canadian Breast Cancer Foundation Fellowship Competition
4