IPHU Registration

Personal Information

First Name *

Last Name *

Gender *

Male
Female
Other

Date of birth *//

Nationality *

Country of residence *

City *

Contact Information

Preferred Email ID *

Alternate Email ID *

Mobile *

Professional Information

Title, Affiliation or Profession *

Institution *

Institution Website / URL

City, Country *

Education *

Please describe your educational background

Occupation *

Please describe your current ocupation

Previous and Current Health Activism *

Please describe your involvement with health activism

Why is the course on Access to Covid-19 Medical Products important for you and your activism? *

Why do you want to participate in this course and what do you hope to be able to do afterwards?

Area of interests

Please list areas of particular interest relating to health and access to medical products

References:

Please provide contact details (name, occupation, email, contact number (preferably mobile) of at least one reference who can speak about your health background/activism.

Reference *

Language Skills

English *

Excellent
Good
Fair
Poor

Any other language (please type in box) *

Skills (Language 3) *

Excellent
Good
Fair
Poor

Online Course Necessities

Do you have access to a reliable computer/laptop *

Yes
No

Do you have access to a reliable internet connection *

Yes
No

Do you agree to commit at least 10 hours every week towards the course and course work *

Yes
No

There will be two class per week ( 3 hours). Which is the timing of your preference for the class? *

9 AM GMT (11 am Cape Town & Cairo / 2:30 pm Delhi)
12 PM GMT (2 pm Cape Town & Cairo / 5:30 pm Delhi)

(Kindly note that the organisers will take the final decision between 9 AM GMT and 12 PM GMT)

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