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Patient Fellowship Application

TIMELINE:

Deadline for submission of completed applications 22 November 2012
Notification of applicants 14 December 2012
25th Annual EuroMeeting, RAI, Amsterdam 4-6 March 2013

All patients organisation representatives who would like to participate in the Fellowship Programme should complete the application form and email to Maureen.mcgahan@diaeurope.org

Fellowship Coordinator:
Maureen McGahan
DIA Europe
+41 61 225 5160 (direct)
+41 61 225 5151 (customer services)
maureen.mcgahan@diaeurope.org

Application

GENERAL INFORMATION
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Section 2
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ORGANIZATION PRIORITIES
Which best describes your organizations funding priority? Choose one.



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CONSTITUENTS
Which best describes the constituents you serve? (choose one)

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INDIVIDUAL EXPERIENCE
Which best describes your skills and experience? (choose two)






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How did you first learn about the DIA Patient Advocate Fellowship Program? (check all that apply)




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SPEAKER REQUEST
If you are a patient in addition to being a representative of your organization are you willing to speak or be on a panel?

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ACCESSIBILITY REQUIREMENTS
Do you have specific accessibility requirements

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EURO MEETING APPLICANTS ONLY
I understand that English is the business language of the 25th Annual EuroMeeting 2013 I am confident of my ability to participate in the meeting.

I understand that I would be required to pay my own travel accommodations and other expenses.