Create Participant Registration Form

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Language:

Type of registration: *

Individual registration

As a part of organization's registration

Select group: *

If your group name is not listed, please get back to register the group first.

Personal information

First name: *

Family name: *

Gender: *

Date of birth: *

Month: *

Day: *

Year: *

Place of origin

Country: *

City: *

Place of residence

Country: *

City: *

Contact Information

Email: *

Alternative emails:		Order

Skype ID:

Mobile Phone number:

- Please provide at least one reliable telephone number. - Example: + (Country code) (City code) (Phone number)

Home Phone number:

Office Phone number:

Postal address:

Professional information

Title, affiliation or profession:

Institution:

Country:

City:

Institution email:

Institution web:

Record of activism

Have you been involved with the PHM?: *

How?: *

Please provide a short note on your activism with the PHM at national, regional or global levels.

Please provide a short account on your health activism in general .: *

Financial support

Do you need financial support?: *

The available funds for financial support are extremely limited. We wish that you can obtained your financial support from other sources.

for: *

You can choose 'travel' and 'accommodation' by select travel then press Ctr+ accommodation

Please provide a short account to justify the financial assistance.:

Please note that the funds available to provide financial assistance are very limited and the decision is also subject to consultation with PHM country and regional circles.

Can you provide solidarity support for participats from the south?: *

How much?: *

We kindly request you to pay the amount you have indicated at the time of registration during the Assembly

USD: *

Paying the registration fees:

Please note that the registration fees is mandatory and should be paid at the registration desk during the Assembly

Can you obtain institutional support for paying the registration fees?: *

Are you a student?: *

Are you willing to volunteer for tasks duriung the Assembly?:

Which area you would like to join?:

You can choose multiple options by holding Ctr key

What is your mother tounge?: *

What are the other languages you master?: *

You can choose multiple options by holding Ctr key