Membership

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?*

—Please choose an option—YesNo

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 and country 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*

AnguillaAntigua and BarbudaArubaBahamasBarbadosBelizeBermudaBonaireCayman IslandsCubaCuracaoDominicaDominican RepublicGrenadaGuadeloupeGuyanaHaitiInternationalJamaicaMartiniqueMontserratRegionalSabaSaint EustatiusSaint Kitts and NevisSaint LuciaSaint MaartenSaint Vincent and The GrenadinesSurinameTrinidad and TobagoTurks and Caicos IslandsVirgin Islands BritishVirgin Islands U.S.

Organisational Structure and Governance

21. What is the governance structure of your organisation?

Board of DirectorsTrusteesCouncilOther

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

26. Website

27. Facebook

28. 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?*

—Please choose an option—YesNo

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?*

—Please choose an option—YesNo

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?*

—Please choose an option—YesNo

If yes please explain:

Member Declaration

34. How would you categorise your Organisation?*

NCD Health NGONON NCD Health NGOAcademiaOther

If other please specify:

35. Which NCDs does your organisation focus on?*

Check as many that apply.
DiabetesHypertensionCancerMental HealthAsthmaRespiratory and AllergyRenal DiseaseObesity PreventionGeneral NCD Prevention and SupportBreastfeeding and Children's HealthEndometriosis and Polycystic Ovary Syndrome (PCOS)Other

If other please specify:

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

Please List here:

37. 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.