WAPO Membership Application Form

Thank you for your application. WAPO will respond within 2 weeks after receipt of your application.

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* 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?

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* 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?

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* 3. DETAILS OF KEY CONTACT AT YOUR ORGANIZATION
Representative needs to have patient experience themselves.

Name:

Phone (incl. international code):

Do you speak English?

Position in organization:

Email:

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* 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)

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* 5. WHERE DOES THE ORGANIZATION OPERATE?

Nationwide

Local / state / province (city wide)

International

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* 6. WHAT ARE YOUR SOURCES OF FUNDING? (Select all that apply)

Donations

Membership dues

Government

Pharmaceutical sponsorship

Fundraising

Grants

Other (please specify)

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* 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)

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* 8. PLEASE STATE DISEASE PREVELANCE IN YOUR COUNTRY AND SOURCE OF INFORMATION

Acromegaly?

Cushing's Disease?

Adrenal Disorders?

Prolactinoma?

Non-Functioning Tumour

Other

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* 9. HOW MANY MEMBERS DOES YOUR ORGANIZATION HAVE?

Patient members:

Family or Carer members:

Health Care Providers:

Non-pituitary staff:

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* 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)

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* 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.

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* 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

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* 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.

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* 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 muriel.marks@wapo.org

Subscribe to WAPO Blog ‘Global Pituitary Voice’

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?

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* 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.

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* 1. YOUR ORGANIZATION

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* 2. Structure of your organization:

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* 3. DETAILS OF KEY CONTACT AT YOUR ORGANIZATIONRepresentative needs to have patient experience themselves.

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* 4. TYPE OF ORGANIZATION (select more than one if appropriate)

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* 5. WHERE DOES THE ORGANIZATION OPERATE?

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* 6. WHAT ARE YOUR SOURCES OF FUNDING? (Select all that apply)

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* 7. WHICH DISEASES ARE REPRESENTED IN YOUR ORGANIZATION?

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* 8. PLEASE STATE DISEASE PREVELANCE IN YOUR COUNTRY AND SOURCE OF INFORMATION

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* 9. HOW MANY MEMBERS DOES YOUR ORGANIZATION HAVE?

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* 10. WHAT SERVICES DO YOU PROVIDE YOUR MEMBERS?

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* 11. REGISTERED MEMBERSHIP WITH WAPO

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* 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.

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* 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.

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* 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.

* 3. DETAILS OF KEY CONTACT AT YOUR ORGANIZATION
Representative needs to have patient experience themselves.

* 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.

* 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.