Colansa membership form - organization/institution


Dear Sir/Madam

Please, answer the questions below to apply for a membership to the Comunidade de Práctica Latinoamérica y Caribe Nutrición y Salud (Colansa) as an organization /institution.

We would like to enphasize that all the information provided here is confidential and will not be available to anyone without your authorization.


Information about the organization /institution
Description (optional)
Full name: *
Founded in:
Website and/or social media: *
Organization /institution address:
Organization /institution phone number:
Organization /institution email: *
Please explain how the organization/institution works or indicate an email address where we can ask information about the purpose, values,  principles and clarify information about the organization /institution that you represent. 
How did you find out about Colansa? *
Details of the member of the organization/institution responsible for the application of this membership
Description (optional)
Full name
 *
What is your current occupation (activity, position or role)? *
Mobile phone number
Do you accept to be included in the Colansa's  Whatsapp group? *
Email address
 *
Do you accept to receive emails from the Colansa's membership group? *
Do you accept to receive the Colansa's newsletter (each two months)? *
How do you think you can contribute to Colansa?
Do you agree with Colansa's conceptual and political framework ?


*
Required
If you answer no to the question above, please write down the reasons that you don't agree with Colansa's conceptual and political framework
Do you agree with the Colansa's

Manifesto for healthy and adequate food in Latin America and the Caribbean ?

*
Required
If you answer no to the question above, please write down the reasons that you don't agree with  Colansa's

Manifesto for healthy and adequate food in Latin America and the Caribbean

Do you have any conflict of interest to declare?

Situations that involve conflict of interests are: activities and/or partnerships (financially funded or not) with industry, companies or organizations that are related to products, practices or politics that are not aligned to the Colansa’s conceptual and political framework, as well as to participation in activities and/or strategic decisions making.

Examples from products, activities and/or services that are related to conflict of interests are: baby food producst, breastmilk substitutes and related products intended for children under 3 years of age, in accordance with current legislation; ultra-processed foods and beverages; firearms; tobacco; alcohol; pharmaceutical products; synthetic agrochemicals; genetic manipulation or patenting of seed; those that violate human rights, labour and/or fundamental rights; those involved in child labour, slave practice in any of the production stages of their products; those involved in acts of violence against men and women or any other form of discrimination and racism against any person; and those that cause disasters or environmental contamination; and food supply conglomerates.

*
If you answered yes to the question above, please give details about what kind of conflict of interests (such as type and the name of the industry).
Thanks for filling out the form!
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