YP-CDN ETHIOPIA Membership Registration form JUNE 2017
* Required
Title
Last Name/Surname
*
Your answer
First Name
*
Your answer
Email address
*
Your answer
Date of Birth
MM
/
DD
/
YYYY
Gender
Male
Female
Clear selection
Which town are you based in?
Gondar
Addis Ababa
Jimma
Dessie
Diredawa
Mekelle
Hawassa
Other:
Clear selection
Which is your field of focus/expertise?
*
Medicine
Law
Business
Engineering
Teaching
Nutrition
Agriculture
Art & Design
nursing
pharmacy
psychatry
medical laboratory
optometry
anesthesia
health officer
midwifery
enviromental healt
Other:
What are your main areas of interest? Check only 3 areas.
*
Diabetes
Cancer
Tobacco Control
Heart Disease
Road Traffic Injury
Access to Medicines
chronic Respiratory Diseases
Other:
Required
What are some of your additional skills that you can help YP-CDN Ethiopia with?
Tick all that apply
Blogging
Photography
Events Planning
Advocacy
IT and Design
Public Speaking
Data analysis
Communication
Other:
Which YP-CDN Ethiopia programmatic areas do you want to volunteer with?
Rheumatic heart disease clubs
Blogging
Social media
Events planning
Research
Advocacy
Fundraising
Access to medicines
Health Policy
Nutrition
Cancer Activities
Diabetes activities
Tobacco Control
None
Other:
In what capacity do you want to volunteer for YP-CDN Ethiopia?
Describe any area you will be comfortable working in.
Your answer
How much time can you volunteer for the period from Jun-Dec 2017? (Kindly be as detailed as possible)
4hrs weekly
only weekends
once a month
single projects
Other:
Clear selection
If you have volunteered before, please give details of where you have volunteered, for how long and describe your volunteer role.
Your answer
Why do you want to Join YPCDN?
*
Your answer
If you are a student, please write the name of your institution that you are affiliated with.
Your answer
If you are working, Kindly write name of employer/instiution
Your answer
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