Application for Individual Healthcare Professional or Scientific Researchers

Join the Lipedema World Alliance today. Working together we can make a change!

Please enable JavaScript in your browser to complete this form.

Name of Applicant

First

Last

Place of birth

Country of birth

Date of birth

Street Address including region or state

Address Line 1

City

State / Province / Region

Postal Code

Country

Contact email address

Contact phone number (including country code)

Personal Identification:

- ID card/passport/driving licence etc... - Tax Identification number:

Country in which you carry out your lipedema related activities

Do you have any actual or potential conflicts of interest (whether commercial or ideological) relevant to LWA membership or activities?

If YES please state

Do you understand that you must proactively report any changes to your conflicts and potential conflicts of interest as they occur, and failure to do so may result in your membership being terminated?

Please upload a copy of your CV (and any other supplementary sheets) describing your experience treating and/or researching lipedema.* Please ensure it provides details of your relevant publications. (You can upload documents not in English, provided we can automatically translate them with Google or Deepl).

Click or drag files to this area to upload. You can upload up to 3 files.

Only the following file formats are permitted: doc (docx), ppt (pptx, pps, ppsx), odt, pdf, xls (xlsx). Maximum file size 15 MB

It is necessary for a Founder Member or a current Board Member of the LWA to support your application.* Please upload a letter or email from them here, supporting your application

Click or drag files to this area to upload. You can upload up to 3 files.

Only the following file formats are permitted: doc (docx), ppt (pptx, pps, ppsx), odt, pdf, xls (xlsx). Maximum file size 15 MB

If there are any areas you want to expand on to support your application, confirm your alignment with LWA values, or any other matters that should be brought to the attention of the Board for your application to be considered, please state them here

Consent request to the Applicant/Contact Person/Appointed Representative

Do you agree that LWA may publish on its web and other media (e.g. social networks linked to LWA) the following data: full name, address, landline, mobile phone, fax, e-mail, membership position (e.g. founder, member, etc.), professional activity, in order to achieve the association's aims as set out in the Statute?

YES, PLEASE
NO, THANK YOU

I have read the PRIVACY POLICY.

Application for Individual Healthcare Professional or Scientific Researchers

Consent request to the Applicant/Contact Person/Appointed Representative

CONNECT