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IPPOSI Patient Education Programme - Application Form
PART A – GENERAL INFORMATION
1.
Title
2.
Name
First Name:
Last Name:
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
4.
Full postal address
Street
Town
County
Postcode
5.
Phone (with area code)
6.
Email (please ensure that your email is entered correctly, as all further correspondence will be via email)
7.
How did you hear about the IPPOSI Patient Education Course?
IPPOSI website
IPPOSI social media
IPPOSI newsletter
IPPOSI member organisation
Other (please specify)
8.
Name of Patient Organisation (if applicable)
9.
Mission of the organisation: (please limit your response to maximum 50 words)
10.
Contact details of your organisation
Street
City
County
Postcode
Phone
Email (general)
11.
Job Title (only for employees)
12.
Current duties:
13.
Total experience in the current organisation:
Years
Months
14.
Total experience including previous experience in other patient organisations:
Years
Months