Name of Organization:
Full address:
City:
State/Province:
Postcode:
Country:
Phone (including international code):
Email:
Name: Position in Organization: Phone (including international code): Email: Do you speak / write / read English?:
Community (no legal entity)Incorporated / RegisteredNot for Profit OrganizationFor Profit OrganizationOther Other (please specify):
InternationalNation wideLocal / state / province (city wide)
Regional (please specify)
Membership duesDonationsCorporateGovernmentPharmaceutical sponsorshipGrantsFundraising eventsOther Other (please specify):
All pituitary and adrenal disorders (adult & children)All pituitary and adrenal disorders (adults only)All pituitary and adrenal disorders (children only)Only adrenal disordersSome pituitary disorders
Please specify
Acromegaly Cushing's Disease Adrenal disorders Other pituitary disorder Other
Patient members Family / carers / other
Social support meetings to personally interactPatient educational meetings and workshopsEducation resources and informationNewsletter / MagazinePhone or email buddie register to communicate with othersTeleconferencing supportCommunication forumComprehensive database on diseases and treatmentsAdvocacy for medications / government / otherOther Other (please specify)
YesNo
