WAPO Membership Application Form Thank you for your application. WAPO will respond within 2 weeks after receipt of your application. OK Question Title * 1. YOUR ORGANIZATION Name of Organization: Full address: City: State/Province: Postcode: Country: Phone (incl. international code): Email: Website Link: Social Media Link: What is the main language used in your organization? OK Question Title * 2. Structure of your organization: Please supply details of people with governance (able to make decisions) in your organization: How many of these are patients or family members of a patient? OK Question Title * 3. DETAILS OF KEY CONTACT AT YOUR ORGANIZATIONRepresentative needs to have patient experience themselves. Position in organization: Name: Do you speak English? Phone (incl. international code): Email: OK Question Title * 4. TYPE OF ORGANIZATION (select more than one if appropriate) Community (no legal entity) Incorporated / Registered Not for Profit Organization For Profit Organization International Other (please specify) OK Question Title * 5. WHERE DOES THE ORGANIZATION OPERATE? Nationwide Local / state / province (city wide) International OK Question Title * 6. WHAT ARE YOUR SOURCES OF FUNDING? (Select all that apply) Donations Membership dues Government Pharmaceutical sponsorship Fundraising Grants Other (please specify) OK Question Title * 7. WHICH DISEASES ARE REPRESENTED IN YOUR ORGANIZATION? All pituitary and adrenal disorders (adult & children) All pituitary and adrenal disorders (adult only) All pituitary and adrenal disorders (children only) Acromegaly only Cushing's/Adrenal only Some pituitary disorders: (please specify) OK Question Title * 8. PLEASE STATE DISEASE PREVELANCE IN YOUR COUNTRY AND SOURCE OF INFORMATION Acromegaly? Cushing's Disease? Adrenal Disorders? Prolactinoma? Non-Functioning Tumour Other OK Question Title * 9. HOW MANY MEMBERS DOES YOUR ORGANIZATION HAVE? Patient members: Family or Carer members: Health Care Providers: Non-pituitary staff: OK Question Title * 10. WHAT SERVICES DO YOU PROVIDE YOUR MEMBERS? Teleconferencing support Communication forum Phone or email buddy system Social support meetings to personally interact Newsletter / Magazine Comprehensive database on diseases and treatments Advocacy Support Booklets and literature Conference Education Other (please specify) OK Question Title * 11. REGISTERED MEMBERSHIP WITH WAPO If you ARE NOT a registered member of WAPO, is your organization interested in becoming a member of WAPO? Ticking this box is considered an application for WAPO membership. OK Question Title * 12. WOULD YOUR ORGANIZATION BE INTERESTED IN NOMINATING ONE REPRESENTATIVE TO ATTEND THE ANNUAL WAPO SUMMIT? The delegate needs to have patient experience themselves, and be a responsible person/decision maker from your organization, who will report back to the organization. Yes No OK Question Title * 13. HOW CAN WAPO ASSIST YOUR ORGANIZATION? After receipt of your information, WAPO will contact you in order to organize a teleconference to discuss the membership of your organization and future activities. OK Question Title * 14. PRIVACY: From May 25th, 2018 the European General Data Protection Regulation will be applicable in all member states to harmonize data privacy laws across Europe.WAPO would like to stay in touch and continue informing you about news, events, webinars as well as informative teleconferences and future developments. We take the privacy of your data very seriously and therefore would like to ask you to consent to receiving these communications. Please tick the communications you wish to receive. You can withdraw your permission at any time by sending an email to firstname.lastname@example.org Receiving WAPO Newsletter ‘Global Pituitary Voice’ – 4 x per year Information regarding WAPO Annual General Meeting Information regarding WAPO webinars (WAPO Members only) Information regarding WAPO Awareness Campaigns Receiving WAPO updates on specific topics Requests for support for specific activities and campaigns by WAPO Invitations for WAPO teleconferences regarding specific subjects Information regarding WAPO Summit Any comments or questions you wish to submit? OK Question Title * 15. Thank you for completing the survey. Your input is of value to WAPO! Should you have additional comments or require further information, please write to us in the box below. OK THANK YOU FOR YOUR INFORMATION!