DIA | Patient Fellowship Application

GENERAL INFORMATION

Prefix

First Name

Last Name

Organization

Job Title

Address

City

Country

State/County/Province

Postal Code

Phone

Alternate Phone

Website

ORGANIZATION PRIORITIES

Which best describes your organization’s funding priority? (choose one)

Advocacy
Biomedical
Research and Drug Development
Education

CONSTITUENTS

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

Major Diseases
Rare/Orphan Diseases

INDIVIDUAL EXPERIENCE

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

Email from third party other than DIA (please specify)

Other: Please specify

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?

Yes
No

ACCESSIBILITY REQUIREMENTS

Do you have specific accessibility requirements?

Yes
No

If yes, please specify.

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.

Yes
No

As there are restricted numbers of fully supported places, if you are selected for the group whose registration fees are waived only, you would be required to pay your own travel and accommodation costs. If this is the case, would you still be willing to attend the EuroMeeting 2013?

Yes
No

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

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Patient Fellowship Application

Application