Civil Society Contact Form

CIVICUS: World Alliance for Citizen Participation, in collaboration with the Inter Press Service (IPS) is developing a database to facilitate the relationship between civil society and the media. This database will contain the names and contact details for civil society organisations as well as their fields of expertise and the regions in which they work. The database will allow the media to quickly and easily find sources for their stories within civil society on a variety of themes.

If you would like to be part of this database, please complete the following form. If you have any questions, please email us at communication@civicus.org.

Fields marked (*) sont obligatoires.

Organisation name: *
Media contact name: *
Job title: *
Address: *
City: *
Country: *
Postal Code: *
Telephone: *
Fax:
Email: *	Valid email address required!
Website:
Twitter ID (If you have one):
Blog (If you have one):
RSS News feed (News feeds may be displayed on the homepage of the database � please only include if you would like your news to be included):
Organisation description (max. 200 words): *	You are only allowed 200 words

Please identify the geographical focus of the organisation:

(Please select at least one geographical focus from the left side, specifying countries are optional)

Local level (district, city, region) within a single country	Specify country:
Single country	Specify country:
Multi-country Africa region	Specify countries (press ctrl to select multiple countries):
Multi-country Americas Region	Specify countries (press ctrl to select multiple countries):
Multi-country Asia Region	Specify countries (press ctrl to select multiple countries):
Multi-country Europe Region	Specify countries (press ctrl to select multiple countries):
Multi-country Oceania Region	Specify countries (press ctrl to select multiple countries):
Global (multiple countries in multiple regions)	Specify countries (press ctrl to select multiple countries):

Please identify theme(s) (and sub-theme(s) where applicable) the organization works in:
* NOTE: Please only select those themes an organisational representative is able to discuss authoritatively with the media.

(Please select at least one theme or sub-theme)

Theme	Sub-theme
Arts, culture and entertainment	Arts and culture Sports
Education	Early childhood care and development Skills development
Religion
Disasters and humanitarian relief
Conflict / War / Peace / Security
Media and Communication	Media/journalism/press freedom Alternative and community media Information Communication Technology
Science and Technology
Economy, Finance and industry	Economy/Trade Microfinance Energy/Extractive industries Agriculture/Farming/Fishing/Forestry
Populations	Gender and Sexuality Indigenous peoples (inc land rights) Ethnicity/Race Men/boys Women/girls Seniors Children/Youth
Migration, refugees and trafficking	Forced Migration/Refugees Slavery/human trafficking
Development issues	Poverty/MDGs Housing Sustainable Development Water/Sanitation
Environment	Animal Welfare/Rights Environment/Conservation Climate Change
Civil Society	Civic Participation and Volunteerism Civil society
Health issues	Disability Health (inc addiction, excl HIV/AIDS) HIV/AIDS Food/Nutrition
Governance, politics and international relations	Governance and Transparency (inc local governance) International institutions (UN, IFIs etc) Globalisation Accountability
Labour issues	Workers rights (inc sex workers)
Justice, law and human rights	Law and legal reform Human rights and social justice

Please indicate the language(s) of communication for the organisation:

(Please select at least one language or specify your language)

English:	French:
Spanish:	Arabic:
Other:

Please upload the organisation�s logo to be displayed along side its profile in the database.
The file size can be no larger then 20KB and the logo will be constrained within a screen area of 100 pixels (height) by 200 pixels (wide) when displayed. The image file must be one of the following formats: Jpeg, Gif or Png.

Organisation logo:

Disclaimer
In completing and submitting this form, you authorize CIVICUS: World Alliance for Citizen Participation and Inter Press Services (IPS) to post the information contained in this form on the database as described above where it will be accessible to the general public. All reasonable precautions will be taken to protect contacts in this database from receiving spam or other unwanted forms of communication. We will not pass on the information in the form of contact lists to any third parties. However, as the database is accessible to the general public, neither CIVICUS nor IPS accept liability for any unwanted forms of communication and their results that may arise from submitting this form. CIVICUS and/or IPS may use the details in this form to send you, from time to time, information we feel may be of interest to you. At any time, should you wish to be removed from the database, please email communication(at)civicus.org.