IPPOSI Patient Education Programme - Application Form

PART A – GENERAL INFORMATION

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* 1. Title

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* 2. Name

First Name:

Last Name:

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* 3. Please indicate if you are:

Employee of a patient organisation

Volunteer of a patient organisation

Patient with a chronic and/or lifelong illness/condition who is not affiliated with a patient organisation

Family member/carer (not affiliated with a patient organisation) of a patient with a chronic and/or lifelong illness/condition

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* 4. Full postal address

Street

Town

County

Postcode

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* 5. Phone (with area code)

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* 6. Email (please ensure that your email is entered correctly, as all further correspondence will be via email)

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* 7. How did you hear about the IPPOSI Patient Education Course?

IPPOSI website

IPPOSI social media

IPPOSI newsletter

IPPOSI member organisation

Other (please specify)

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* 8. Name of Patient Organisation (if applicable)

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* 9. Mission of the organisation: (please limit your response to maximum 50 words)

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* 10. Contact details of your organisation

Street

City

County

Postcode

Phone

Email (general)

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* 11. Job Title (only for employees)

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* 12. Current duties:

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* 13. Total experience in the current organisation:

Years

Months

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* 14. Total experience including previous experience in other patient organisations:

Years

Months