New Country Chapter / Country Representative FormFull Name of Applicant / Contact Person *Country *City / Region *Phone (with country code) *Email *Preferred communication method *EmailWhatsAppPhone callOrganisation (if applicable)Are you applying as… *An individualAn existing organisationOrganisation Name *Organisation Type (NGO, CBO, clinic, association, faith-based, etc.) *Website or social media page(s)Motivation & ContextWhy do you want to start a FibFA chapter or represent FibFA in your country? *Briefly describe the situation of uterine fibroids in your country or community (awareness level, common challenges, cost barriers). *Have you been involved in fibroid-related work before? *YesNo“If yes, please describe your experience (programmes, events, outreach, research). *Capacity & ActivitiesWhat activities do you plan in the first 12 months? (tick all that apply) *Awareness talks in communitiesSocial media campaignsCounselling and support groupsPartnerships with clinics / hospitalsData collection / research supportFundraising for surgery supportOtherIf Other, please describe. *Who will be involved in the chapter? *I already have a small teamI am currently alone but will recruit volunteersDescribe your current team or how you plan to recruit volunteers. *What existing strengths or resources do you have? (venues, networks, media, clinics, etc.) *Expectations & Support NeededWhat support do you expect from FibFA (Ghana)? *Training and educational materialsUse of FibFA name and logoTechnical guidance for programmesHelp with fundraising ideasOther support (please specify)How do you plan to contribute to FibFA’s mission and standards (reporting, branding, ethics)? *Governance & EthicsAre you willing to submit brief activity and financial reports to FibFA? *YesNoAre you willing to use FibFA materials responsibly and not claim medical authority you do not have? *YesNoAre you willing to respect confidentiality and privacy of women seeking help? *YesNoAny legal or registration steps already taken or planned in your country?DeclarationI understand this is an application and does not automatically create a FibFA chapter. All chapter agreements will be confirmed in writing by FibFA. *YesType your full name as your electronic signature *Date *Register
