Participation form

Status message

Thanks to all who contributed and participated in the success of the Change Day initiative, we hope for your participation in the upcoming campaign. Interact with us via social networking.

Name *

Phone Number *

E-mail

Occupation *

Please specify

Specialty

Workplace *

Please specify

Name of institution *

Can we contact you? *

Yes

No

What does your pledge focus for? *

The Pledge *

is there anyone else participating in this pledge? / Is it a group pledge? *

Yes

No

If yes , how many are the participants?

Can we publish your pledge? *

Yes

No

How did you hear about the day change? *

Please specify

Participation form

Status message

TOTAL PLEDGES TO DATE