Membership
Registration
ASK US Positive Children, Adolescents and Youth National Association Membership Registration
1
Personal Information
First Name
*
Middle Name
Last Name
*
Gender
*
Select Gender
Male
Female
Date of Birth
*
Age:
-
Nationality
*
Region
*
Select Region
Addis Ababa
Afar
Amhara
Benishangul-Gumuz
Central Ethiopia
Dire Dawa
Gambela
Harari
Oromia
Sidama
Somali
South Ethiopia
South West Ethiopia
Tigray
Zone
Woreda/Sub-city
Kebele
2
Contact Information
Email Address
*
Phone Number
*
Format: +251-XXX-XXXXXX
Alternative Phone
Emergency Contact Name
Emergency Contact Phone
3
Education & Employment
Level of Education
*
Select Education
No Formal Education
Primary School
Secondary School
Preparatory School
TVET
Diploma
Bachelor's Degree
Master's Degree
PhD
Other
Employment Status
*
Select Status
Student
Government Employee
Private Employee
NGO Employee
Self-employed
Daily Laborer
Farmer
Unemployed
Volunteer
Other
Profession
Organization/School
4
Family Information
Marital Status
*
Select Status
Single
Married
Divorced
Widowed
Family Status
*
Select Status
Living with Parents
Single Orphan (Mother Deceased)
Single Orphan (Father Deceased)
Double Orphan
Guardian Care
Foster Care
Independent Living
Child-headed Household
Other
Number of Dependents
5
Health Information
HIV Follow-up Site
*
ART Start Year
Currently on ART?
Yes
No
Need Psychosocial Support?
Yes
No
Need Peer Support?
Yes
No
6
Skills & Talents
Skills
Languages
Hobbies
Volunteer Experience
7
Documents
ID Document
Click to upload
Your Photo
Click to upload
8
Account Setup
Username
Email
*
Password
*
Confirm Password
*
9
Consent & Agreement
I confirm the information provided is true and accurate.
I understand my information will be kept confidential.
I agree to the Terms & Conditions and Privacy Policy.
Secure Registration
Register as an ASK US Member
