#uniteforsafecare - Supporter • Patient Safety Movement

Name*

First Last

Email*

Phone*

I am a _________*

Patient or family member
Health worker or healthcare administrator
Represent a company or business

Name of Organization

Logo of Organization

Accepted file types: jpg, png, Max. file size: 100 MB.

Please upload a photo of your organization if you would like it to appear on our website as a supporting organization.

Type of Organization*

I'm an individual and do not want to represent an organization
Government Agency
Patient Advocacy Organization
Non-profit
Healthcare Provider (e.g. hospital, pharmacy, clinic)
Insurance Company
Association/society
Other company

Provide a description of the activity or activities that you are planning on World Patient Safety Day to support #uniteforsafecare*

Would you like your activity to be added to our Satellite Events page?*

Yes
No

Here is our Satellite Events page

Activity Details

Please complete the section below if you are planning an activity that you would like to appear on our website under Global Events. We want to show the world that patient and health worker safety is important, so any activity - small or large - can be shared. Your submission will be reviewed by our team and you will be contacted with any questions as well as notified when your event has been posted on our website.

Name of Activity*

Start Date*

Start Time

:

End Date*

End Time

:

Location of Activity

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

The event is:*

open to the public
free of charge
of special interest to patients and families
of special interest to health workers

Event Website

Contact Email for Activity Organizer*

Description of the activity or activities that you'd like to publicly display on our global events page

Acknowledgement*

I agree

I hereby authorize The Patient Safety Movement Foundation (PSMF) and assign the rights to display, publicly perform, exhibit, transmit, broadcast, reproduce, record, photograph, digitize, modify, alter, edit, adapt, create derivative works, otherwise use, and permit others to use, the name, logo(s), publicly available data and images of the person listed above and its relevant affiliates on any platform and for any purpose including, but not limited to, advertising, public relations, publicity, packaging, and promotion of the PSMF without further consent or consideration from the person listed above.

CAPTCHA

Become a supporter - #uniteforsafecare

Activity Details