YP-CDN KE Membership Registration form MARCH-MAY 2017
This is a membership registration form for Young Professionals Chronic Disease Network Kenya. A registration fee of 200Ksh will be levied to become a member. This amount is only payable by MPESA to the number 0707636514 upon completion of the form. You will receive a confirmatory receipt via email within 3 working days.
* Required
Last Name/Surname
*
Your answer
First Name
*
Your answer
Email address
*
Your answer
Date of Birth
MM
/
DD
Gender
Male
Female
Clear selection
Which town are you based in?
Nairobi
Thika
Eldoret
Nakuru
Kisumu
Mombasa
Other:
Clear selection
Which is your field of focus/expertise?
*
Medicine
Law
Business
Engineering
Teaching
Nutrition
Agriculture
Art & Design
None
Other:
What are your main areas of interest? Check only 3 areas.
*
Diabetes
Cancer
Tobacco Control
Heart Disease
Road Traffic Injury
Access to Medicines
Mental health
Health policy
Food Policy
Other:
Required
What are some of your additional skills that you can help YP-CDN Ke with?
Tick all that apply
Blogging
Photography
Events Planning
Advocacy
IT and Design
Public Speaking
Data analysis
Communication
Other:
Which YP-CDN Ke 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 Ke?
Describe any area you will be comfortable working in.
Your answer
How much time can you volunteer for the period from Jan-Jun 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
Institution Affiliated/Employer/School.
Your answer
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