PATIENT VOICES FORM | Rare Diseases SA

patient voices registration form

First Name

Last Name

Phone

Address

Disease Group that you would like to represent?

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, and how can you help make a difference?

What are your ideas in creating awareness/providing support for rare diseases as a whole as well as your specific condition?

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

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?

I want to subscribe to the newsletter.

patient voices

registration

patient voices registration form

patient voices

registration

Read our patient stories here

for a better tomorrow