Application form for ePAG EpiCARE Advocates
Please read carefully the information below and complete the application form. The application will be assessed against the criteria described in the ePAG EpiCARE Terms of Reference. If you have any questions or concerns, please contact epag.epicare@gmail.com
Details of the Patient Organisation
Name of the Patient Organisation (in local language and in English if applicable):
*
Acronym:
Type of an organisation:
*
Patient Organisation
European Federation
International Federation
Other
Disease, condition, syndrome or malformation represented:
*
Is your Patient Organisation legally registered and operating in European countries?
*
Yes
No
Registered address of your Patient Organisation:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Country where your Patient Organisation is registered:
*
Email address:
*
example@example.com
Phone Number:
*
-
Country Code
Phone Number
Website:
*
Legal status of your Patient Organisation:
*
Date in which your Patient Organisation was registered:
*
-
Month
-
Day
Year
Date
Contact person at your Patient Organisation:
*
First Name
Last Name
Email address of the contact person at your Patient Organisation:
*
example@example.com; All informtion regarding this application will be sent to this contact
Phone Number of the contact person at your Patient Organisation:
*
-
Country Code
Phone Number
Number of members of your Patient Organisation:
*
Number of staff working for your Patient Organisation:
*
Number of volunteers in your Patient Organisation:
*
Is your Patient Organisation a member of a National Alliance for Rare Diseases and/or any international organisation?
*
Yes
No
If yes, please provide details:
*
Details of a Candidate for ePAG EpiCARE Advocate
Name:
*
First Name
Last Name
Email address:
*
example@example.com
Country:
*
Role in the Patient Organisation:
*
Staff
Volunteer
Other
Native language:
*
Level of English:
*
Please Select
Native
Advanced
Good
Intermediate
Basic
Other languages spoken and level of competency:
Experience of a Candidate for ePAG EpiCARE Advocate
Do you have knowledge of, or experience of living with, one of the rare and complex epilepsy included in the scope of the ERN EpiCARE?
*
Yes
No
If yes, please indicate in what capacity:
*
Patient
Parent/caregiver
Family of patient
Other
Do you have experience in representing the interests and the needs of your community?
*
Yes
No
Do you have experience in collaborating with clinicians?
*
Yes
No
If you have any experience in these fields, please select the items from this list:
Short biography (max. 250 words):
*
0/250
Short motivation letter (max. 250 words):
*
Please explain why you wish to become an ePAG EpiCARE Advocate, what are your areas of interest and how you meet the skills and experience required.
0/250
Please upload the letter of endorsement signed by a legal representative of your Patient Organisation using the template available on ERN EpiCARE website.
*
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Please upload the file in pdf, doc or docx format, preferably in pdf.
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In case of joining as an ePAG EpiCARE advocate, I agree to my contact details being stored on the ePAG EpiCARE contact database for the purposes of managing my involvement as ePAG advocate.
*
Yes
No
In case of joining as an ePAG EpiCARE advocate, I agree to my contact details being stored on the EURORDIS contact database for the purposes of managing my involvement as ePAG advocate.
*
Yes
No
By signing this form,
I confirm I have read and I agree with the ePAG EpiCARE Terms of Reference.
I understand and agree to the minimum level of commitment required for the role.
I agree that ePAG EpiCARE shares the data included in this application form with the ePAG, the ERN EpiCARE Coordinator and project manager to discuss my application.
Name:
*
First Name
Last Name
Date:
*
-
Month
-
Day
Year
Date
Signature
*
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