Registration Form

If you or your organisation would like to partner with Pratigya: Campaign for Gender Equality and Safe Abortion as an Organisational Partner/ Individual Partner/ Supporting Partner, please fill in the form on this page and click “Submit”.  Click here for the partnership document that describes the scope and responsibilities of being a partner in the campaign.

Organisational Partner   Individual Partner     Supporting Partner
Organisation Information

* Name of Organisation/Individual:

* Address


(Please include Building No, Street Name)

* City/Town

* State

* Pin code

* Country

* Phone:


(Landline No. / Mobile No.)
* Primary Email:

* Geographical scope:
* Reach of your organisation

Community Based
State Level
National Level
International (across several countries)
Contact Persons
Name Designation Email id Skype id

* Kindly provide names of two individuals (normally the Organisation Head and Second in line) One of whom will be expected to regularly attend the Campaign Meetings.

* Organisation's/ Individual's Focus Areas
Access to safe abortion: Service Provision
Access to safe abortion: Education/Knowledge sharing/ Counseling/ Advocacy
Prevention of gender biased sex selection: Education/ Knowledge sharing/ Counseling
Prevention of gender biased sex selection: Advocacy
Family Planning and Access to contraceptives: Provision of commodities and services
Young People
Maternal Health
Violence against women
Gender Issues

Please enlist your membership with other related networks/coalitions:

1.
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5.

* Please indicate issues you would like to collaborate with other Pratigya: partners on:

* Would you/ the organisation be interested in being involved in the regular program activities of the Campaign?

Yes
No

If yes please indicate how many hours in a month you can commit to campaign related work: Also would you be interested and will be able to commit your time to be on the Campaign Advisory Group. 

* Would you/ organisation be open to your organisation’s logo being used on the Campaign documents?
Yes
No
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