Membership Form Individual Membership Form Join a global community committed to fast-tracking responses to communicable diseases, non-communicable diseases, and the health impacts of climate change. SECTION 1: PERSONAL INFORMATIONFirst Name *Middle NameLast NameAcademic Credential(s): *Pronouns: *Please select an optionShe/HerHe/HimThey/ThemSelectOtherPronouns OtherCityState/ProvinceCountry of ResidenceAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint HelenaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. MartinSt. Pierre & MiquelonSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Virgin IslandsUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweNationality:SECTION 2: CONTACT INFORMATIONPrimary Email: *Alternate Email (optional):Phone Number (with country code): *Preferred Method of Contact: *Please select an optionEmailPhoneWhatsAppSelectSECTION 3: PROFESSIONAL BACKGROUNDCurrent Occupation:Title/Position:Organization/Affiliation:Sector *Please select an optionPublic HealthClinical MedicineNursingResearch/AcademiaPolicy/AdvocacyCivil Society/NGOGovernmentStudentOther:SelectAreas of Interest (check all that apply) *Communicable DiseasesNon-Communicable DiseasesClimate and HealthHealth Systems StrengtheningHealth EquityDigital Health and AIUrban/City HealthOtherSECTION 4: MEMBERSHIP BENEFITSWhich of the following benefits are you most interested in accessing? (Check all that apply) *Educational and Training ResourcesCME/CE-Accredited CoursesConference and Event DiscountsPeer Networking and Knowledge ExchangeAdvocacy and Leadership OpportunitiesUpdates on Global Health DevelopmentsResearch Collaborations and Calls for PapersSECTION 5: DIVERSITY AND INCLUSION (OPTIONAL)Fast-Track Health is committed to fostering a diverse and inclusive community. You are invited, but not required, to share the following: Gender Identity:Sexual Orientation:Ethnicity or Racial Identity:Disability Status:YesNoPrefer not to sayLived Experience with Any Health Condition (self-disclosed)YesNoPrefer not to saySECTION 6: TERMS AND CONFIRMATIONCommunications Consent *I agree to receive communications from Fast-Track Health related to membership benefits, events, and updates. Data Consent *I consent to the secure storage and use of my data by Fast-Track Health for the purposes of managing my membership.Credit / Debit Card *Submit
