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* 1. Please provide your full name.

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* 2. What is your current role in the EPF member organisation?

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* 3. Please specify the name of your EPF member organisation.

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* 4. Name of the young patient/representative/carer you are endorsing.

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* 5. Date of birth of the young patient/representative/carer (DD/MM/YYYY).

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* 6. Country of residence of the young patient/representative/carer.

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* 7. Chronic condition being represented (is the candidate a patient and/or patient representative/carer).

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* 9. Current role of the young patient in the EPF member organisation.

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* 10. Will this participant be the one from your organisation having voting rights?

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* 11. Will this participant be a candidate for the EPF Youth Group elections?

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* 12. Reason for endorsing this person (please provide examples of any related patient advocacy, relevant activities within your organisation, membership of your youth group, etc.).

Please, keep your answer to a minimum of 100 and maximum 500 words):

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* 13. Date of endorsement and signature (please, write the date and your full name):

I hereby sign this form...

Note: The European Patients’ Forum can cover travel and accommodation costs if needed. If the Member organisation is endorsing two participants, EPF may cover the second participant’s costs upon availability of funds.

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