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Global Health Program or Individual Member
The information on this form will be used to add you, as an individual network member, or you as a representative of your institution / global health program to the Global Health Pathology Network so that others in the Network can contact you.
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Email address
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Your email
Are you submitting this form as an
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Individual
Institution/Global Health Program
Both institution and individual contact for that institution/global health program
Name of Individual with Affiliation or Name of Institution
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Your answer
Name of Global Health Program within Institution (if applicable)
Your answer
Your expertise and/or Institution's Vision/Mission Statement
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Your answer
Additional contacts (if applicable)
Your answer
General or Region(s) of work or interest to work (please select one or multiple as appropriate)
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General
East Africa
Central Africa
West Africa
Northern Africa
Southern Africa
North America
Central America
South America
Europe
South-East Asia
Eastern Mediterranean
Western Pacific
Other:
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Reason for Interest in GHPN (please select)
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I can provide pathology expertise
I am interested to receive pathology support
I am interested to fund Global Health Pathology work
Other:
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Comments
Your answer
A copy of your responses will be emailed to the address you provided.
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