Membership Database Update

by HCC
HCC Membership Database Update

We are conducting a membership database update, your information is important to us so please complete as much information as you can.

Fields marked with a red asterisk* are mandatory.

Thank you for taking the time to complete this form.

If you have any questions please contact us.

    General Information

    1. Name of person completing the form*

    2. Position of person completing the form*

    3. Name of Organisation* (This will be displayed as your webpage title)

    4. Upload your logo Max:5mb (files allowed pdf|png|jpg|jpeg)

    5. Upload an Image Max:5mb (files allowed png|jpg|jpeg)
    (Please attach here a high-resolution image you would like to have on the top of the webpage. It should be different to your logo, for example, it could be an image of a recent campaign, meeting or activity your organisation has organised. Recommended size: 780 x 520px.)

    6. Mission statement/vision/slogan*

    7. Tell us about the work your organisation does*
    Please include specific focus areas e.g. NCDs, Environmental Issues, Youth Engagement, Gender

    8. In what year was your organisation formed or founded?*

    9. Does your organisation have a youth arm or youth group?*

    10. If yes, what is the name of the youth arm and the primary contact person?

    11. Does your organisation undertake work in any of the HCC pillars? Please check all which apply.

    AccountabilityAdvocacyCapacity DevelopmentCommunicationSustainability

    Contact Information

    Only your organisation email address, country and social media links will be public on HCC’s website

    12. Primary Contact Name*

    13. Role of Primary Contact*

    14. Primary Contact Email*

    15. Secondary Contact Name

    16. Role of Secondary Contact

    17. Primary Secondary Email

    18. Organisation Contact Email*

    19. Postal Address

    20. Your Country*

    Organisational Structure and Governance

    21. What is the governance structure of your organisation?

    If other please state

    22. Name of President, CEO, and/or Chairman

    23. Contact Email or Designated Secretary Email

    Documentation

    24. Proof of Legal Registration Max:2mb (files allowed pdf|doc|docx|jpg|jpeg)

    25. Constitution/Bye Laws/Rules (if any) (files allowed pdf|doc|docx|jpg|jpeg)

    Website and Social Media Information *Please provide the URL for each account e.g. https://www.instagram.com/healthycaribbean/

    26. Website

    27. Facebook

    28. X (Twitter)

    29. Instagram

    30. YouTube

    Conflict of Interest

    31. Does your organisation, its governing members and/or its close associates have a relationship with any entity directly involved in the production, manufacture, distribution or sale of tobacco or any tobacco products, or directly representing the interests of any such entity?*

    If yes please explain:

    32.Does your organisation, its governing members and/or its close associates have a relationship with any entity directly involved in the production, manufacture, distribution or sale of alcohol or alcoholic beverages, or directly representing the interests of any such entity?*

    If yes please explain:

    33. Does your organisation, its governing members and/or its close associates have a relationship with any entity directly involved in the production, manufacture, distribution or sale of food, or non-alcoholic beverages – namely ultra-processed and HFSS foods and beverages[1], or directly representing the interests of any such entity?*

    If yes please explain:

    [1] ultra-processed and HFSS food and beverages industry” relates to manufacturers of nutrient poor foods and beverages, including high in fat, sugar, and/or salt (HFSS) including sweet beverages, sweet or savory packaged or unpackaged snacks, infant formulas, follow-on milks and other baby food products, reconstituted meat products and pre-prepared frozen dishes, which are not modified foods but formulations made mostly or entirely from substances derived from foods and additives. In addition, it includes business associations, front groups or other non-state actors representing or funded largely by any of the afore- mentioned entities.

    Member Declaration

    34. How would you categorise your Organisation?*

    If other please specify:

    35. Which NCDs does your organisation focus on?*

    Check as many that apply.

    If other please specify:

    36. Are you interested in joining any of the below disease-specific groups or our CSO Action Team? These groups meet monthly or quarterly to discuss upcoming activities and campaigns in the region. It provides a platform for member CSOs to stay informed and collaborate. Upon joining, you will be added to a WhatsApp group for communication. Please check all which apply.

    Diabetes Member CSOsCancer Member CSOsHeart/ Stroke Member CSOsCSO Action Team

    37. Please provide your WhatsApp number to be added to the group:

    38. Are there any individuals within your organization whom you would recommend to join the following groups?

    • People Living with Non-Communicable Diseases (PLWNCD)

    • Healthy Caribbean Youth (HCY)

    If so please provide the contact information of the person and the group they are recommended for.

    39. Are there any other CSOs in your country that may be interested in joining the HCC Membership?

    Please List here:

    40. From time to time HCC will send open letters and statements to Governments, Organisations etc. on behalf of the HCC board, Staff and Members, if you wish your organisation to be included in this type of advocacy please check this box.

    Yes please include me

    By clicking submit you hereby confirm that the information contained in this form is correct to the best of your knowledge and that you are in the capacity to submit this on behalf of your organisation.

    Submission can take a couple of minutes depending on the size of the images/documents you are sending so please do not click the submit button twice, wait until the success message is displayed.

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