Personal DetailsName* Position* Phone Number* Email* What motivated you to be an advocate for NCDs+? (Not more than 200 characters):*Health conditions & risk factorsPlease indicate all that apply to you or your organisation.Health Conditions Air Pollution Blood disorders, state type Bone and joints, state type e.g. rheumatoid arthritis Cancer, state type of cancer Cardiovascular conditions, state type e.g. high blood pressure, stroke, heart disease Chronic Fatigue Syndrome Ears/hearing Endocrine/metabolic e.g. diabetes, thyroid disorders, high lipids Eyes/blindness Food, nutrition, obesity and under nutrition Kidney disease Mental conditions e.g. depression, bi-polar, eating disorders, Neurological conditions, state type e.g. dementia, migraine, Parkinsonism, Epilepsy Psoariasis and other autoimmune and skin conditions Reproductive e.g. Endometriosis Substance abuse e.g tobacco, alcohol etc Respiratory conditions, state type e.g. TB, asthma, COPD, cystic fibrosis Water Resources Other SpecifyOther Specify Which age and stage do you focus on?Age and Stage: Select All Adolescents All ages Children Infants/babies Mothers and babies Public sector Senior citizens Vulnerable groups- specify: asylum seekers, disability, poverty Youth Other SpecifyOther Specify Type of service offeredType of service offered Select All Advocacy Clinical care Counselling Education Policy Research Residential care Support groups Other SpecifyOther Specify Continuum of careContinuum of care Select All Disability Health promotion Palliative care Prevention: specify type of prevention Primary health care Rehabilitation Screening Social determinants of health Treatment/care Other SpecifyOther Specify Website Facebook Link Instagram Link Twitter Link Conflict of interest statement* I certify that i am not funded, sponsored, supported or influenced by the alcohol, tobacco, food & beverage, fossil fuel extraction or arms industries. Consent*SANCDA takes data protection seriously. Please read our privacy policy for information on how we handle your data and what your rights are. By completing this form I agreed to the collection, and use of information by SANCDA to share my organisations details and to contact me.CAPTCHA
