Brain Hub Moderator Agreement
Please complete this form in order to be acquainted with the operations of the Global Online Patient Support Hub. Thank you for your willingness to help!
Email address *
Name *
First and Last Name (Surname)
Your answer
Email *
Your answer
Primary Telephone Number (Please include country code, city code and telephone number): *
Your answer
Secondary Telephone Number (Please include, country code, city code and telephone number): *
Your answer
Home Address (Please include street number, street name, city, region and country): *
Your answer
Which position(s) are you interested in? *
Required
What is the name of the disease that is of interest to you as a moderator or buddy? *
Your answer
Please tell us about your connection to the relevant disorder of the group. *
Your answer
Please attest to the following statements.
After reviewing the Global Online Support Hub Use Policies (which include the Terms of Use and Code of Conduct, located via www.BrainPatient.org), please place a check in the box to affirm your agreement to the following policies. *
Required
You affirm that you have read the above statements carefully and that you have personally agreed with each of these policies. Please electronically sign below. Thank you!
E-signature: *
Your answer
A copy of your responses will be emailed to the address you provided.
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