CoCP APPLICATION FORM

Circle of Cleft Professionals (CoCP) Membership Application Form

Thank you for your interest in the Circle of Cleft Professionals (CoCP).

We are a worldwide network of cleft professionals and cleft charity leaders with an interest in promoting Comprehensive Cleft Care (CCC) in resource-constrained contexts.

The objectives of the CoCP are to:

1) Facilitate collaboration and networking among Cleft Professionals with an interest in multidisciplinary care in low and middle-income countries.

2) Communicate the impact and learning occurring within CCC projects

3) Support local teams' growth in implementing CCC

If you would be interested in joining this network, please complete the brief application below.

Once your application has been received, we will review your application and respond within 7 days by email.

If you have any questions about this application, please feel free to e-mail: info@cleftcircle.org

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* 1. Please provide your contact information:

Name

Email Address

Phone Number

City/Town of Professional Practice

Country

Your full mailing address including ZIP/ Postal Code

Name of hospital/ clinic/ organization you are affiliated with:

Position

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* 2. What is your primary area of speciality in the cleft field? (choose 1)

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* 3. What are your areas of interest in the cleft field? (check all that apply)

Pre-surgical orthodontics (e.g. NAM)

Pre-surgical nutrition

Innovations in cleft care (e.g. Surgical simulation)

Research (e.g. Cleft epidemiology)

Evidence based approach (e.g. Case management, Electronic Medical Records)

Alternative service delivery models (e.g. Training non-professionals)

Social support for cleft families

Complex cases

Resource development (e.g.Grant writing, fundraising)

Multidisciplinary Team Management

Other (please specify)

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* 4. Which, if any, international cleft care NGOs are you (or the organization you work for) currently affiliated with? Please select all that apply.

Akila Bharatha Mahila Seva Samaja (ABMSS)

CLEFT Charity UK

Deutsche Cleft Kinderhilfe (DCKH)

European Cleft Organization

Fundacion Gantz

Global Smile Foundation

Noordhoff Craniofacial Foundation (NCF)

Operation Smile

Project Harar

Smile Train

Transforming Faces

None

Other (please specify)

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* 5. How did you hear about the Circle of Cleft Professionals (CoCP)?

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* 6. Why would you like to join the CoCP?

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* 7. What are your questions or suggestions for us as we support this program?

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* 8. Who else should we invite to join the CoCP? We would be grateful for your referral below: (optional)

Name

Speciality

Hospital/Clinic/ Organization