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:

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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

Partners