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.
Last Name/Surname *
First Name *
Email address *
Date of Birth
MM
/
DD
Gender
Clear selection
Which town are you based in?
Clear selection
Which is your field of focus/expertise? *
What are your main areas of interest? Check only 3 areas. *
Required
What are some of your additional skills that you can help YP-CDN Ke with?
Tick all that apply
Which YP-CDN Ke programmatic areas do you want to volunteer with?
In what capacity do you want to volunteer for YP-CDN Ke?
Describe any area you will be comfortable working in.
How much time can you volunteer for the period from Jan-Jun 2017? (Kindly be as detailed as possible)
Clear selection
If you have volunteered before, please give details of where you have volunteered, for how long and describe your volunteer role.
Why do you want to Join YPCDN? *
Institution Affiliated/Employer/School.
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