Online Submission Form

Full Name*

First NameLast Name

E-mail*

[email protected]

What is the name of your organisation?*

Is your organisation a Full or an Associate Member of EURORDIS? *

What disease(s) is(are) represented by your organisation?*

Please provide your organisation's country*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Country*

What describes you best? Being a:*

If you chose "Other" at the previous questions, please specify here.

Are you or your organisation other networks or groups relevant in rare diseases and/or mental health e.g.: National Committee/Task Force/ Working Group please specify which one(s)

What is your relevant personal / professional background?*

What is your English level?*

BeginnerIntermediateAdvancedNative

Does the rare diseases you represent impact on mental health and wellbeing of those living with the rare disease? If so, please indicate the rare disease and describe how mental wellbeing is affected?

Would you be willing to dedicate, on average, 4h/month to EURORDIS Mental Wellbeing Partnership Network?*

YesNoNot sure

On a scale from 1-5 (1 being the lowest level and 5 being the highest level) please assess the following questions: *

1 is Worst, 5 is Best

How would you evaluate your understanding of the mental health?*

How would you evaluate your interest in the mental health area?*

Almost there... Please describe in a few words why you would like to join EURORDIS Mental Wellbeing Partnership Network*

Application form