PATIENT VOICES SIGNUP | Rare Diseases SA

Patient Voices Registration Form

First Name

Last Name

Phone

Address

Disease Group that you would like to represent?

Are you on Facebook?

Are you on Twitter?

Are you on Instagram?

Are you on LinkedIn?

Do you have WhatsApp on your phone?

Do you have access to internet?

Do you have access to a computer with an internet connection if required?

What are your areas of expertise (Ie: media, story telling, arranging events, communications etc)

Why do you want to be an Ambassador for Rare Diseases SA?

Is there any other information you feel we should be aware of?

Please upload a suitable profile picture for us to include on our website and social media:

Upload File

Upload supported file (Max 15MB)

Do you agree to represent our Rare Diseases SA community in public with integrity and respect, in accordance with our vision, mission and brand values?

Do you agree to fund-raise (where possible) for Rare Diseases SA NPC?

Thanks for submitting!

Patient Voices Registration Form

Read our Patient Stories here

TELEPHONE +27 72 476 7552

EMAIL ADDRESS

Patient Voices Registration Form

Read our Patient Stories here

TELEPHONE +27 72 476 7552

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EMAIL ADDRESS hello@rarediseases.co.za

EMAIL ADDRESS