Application form
Full Name
*
First Name
Last Name
E-mail
*
example@example.com
What is the name of your organisation?
*
Is your organisation a Full or an Associate Member of EURORDIS?
*
Please Select
Full Member
Associated Member
Not a Member of EURORDIS
What disease(s) is(are) represented by your organisation?
*
Please provide your organisation's country
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Country
*
What describes you best? Being a:
*
Parent / Caregiver
Patient
Clinician
Research
Other
If you chose "Other" at the previous questions, please specify here.
Are you or your organisation other networks or groups relevant in rare diseases and/or mental health e.g.: National Committee/Task Force/ Working Group please specify which one(s)
What is your relevant personal / professional background?
*
What is your English level?
*
Beginner
Intermediate
Advanced
Native
Does the rare diseases you represent impact on mental health and wellbeing of those living with the rare disease? If so, please indicate the rare disease and describe how mental wellbeing is affected?
Would you be willing to dedicate, on average, 4h/month to EURORDIS Mental Wellbeing Partnership Network?
*
Yes
No
Not sure
On a scale from 1-5 (1 being the lowest level and 5 being the highest level) please assess the following questions:
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
How would you evaluate your understanding of the mental health?
*
How would you evaluate your interest in the mental health area?
*
Almost there... Please describe in a few words why you would like to join EURORDIS Mental Wellbeing Partnership Network
*
Submit
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