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