2016 Self-nomination Form - 4th Rare Diseases Health Policy Focus Group - London 8-10 December 2016

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* 1. Thank you for your interest in participating in the 4th Rare Diseases Health Policy Focus Group taking place in London 8-10 December 2016. Please provide your name, country of practice, title, affiliation, email address and phone number

Name:

Country:

Title:

Affiliation:

Email:

Phone:

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* 2. Please copy and paste your latest biography into the box below (up to 400 words)

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* 3. Please describe what you feel your contribution to the Summit will be? (up to 400 words)

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* 4. Do you have a role in the decision making process of policies in your country? (Please provide further information on your role/work next to each option)

Government - Health Ministry:

Government Committee:

Medical Association - Committee:

Academic Institution - Research:

Health Policy Institution:

Advocacy Groups:

I am simply interested: