NACOPHA - Membership Registration

Personal Information

Taarifa Binafsi • Tell us about yourself

First Name * / Jina la Kwanza

Middle Name / Jina la Kati

Last Name * / Jina la Ukoo

Date of Birth * / Tarehe ya Kuzaliwa

Gender * / Jinsia

👨

Male

Mwanaume

✓

👩

Female

Mwanamke

✓

Phone Number * / Namba ya Simu

Email Address * / Barua Pepe (for login) This will be your username for login / Hii itakuwa jina lako la kuingia

National ID (NIDA) / Namba ya Kitambulisho

Address Information

Mahali Unapoishi • Where do you live?

Region * / Mkoa

District * / Wilaya

Ward * / Kata

Street/Village / Mtaa/Kijiji

ℹ️

Why do we need this?

Your address helps us connect you with local NACOPHA networks and services in your area. / Anwani yako inatusaidia kukuunganisha na mitandao ya NACOPHA karibu nawe.

Health Information

Taarifa za Afya • Confidential health details

🔒

Your Privacy is Protected

This information is strictly confidential and will only be used to provide you with appropriate support. / Taarifa hizi ni siri na zitatumika kukusaidia kupata huduma zinazofaa.

Are you currently on ART? * / Je, unatumia dawa za ARV?

💊

Yes

Ndiyo

✓

❌

No

Hapana

✓

🤐

Prefer not to say

Sipendelei kusema

✓

Year of Diagnosis / Mwaka wa Kugundulika

Health Facility / Kituo cha Afya

Membership

Uanachama • Membership Registration

REGISTRATION FEE / ADA YA USAJILI

TZS 18,000

TZS 15,000

Registration Fee
Ada ya Usajili

TZS 3,000

First Month Fee
Ada ya Mwezi wa Kwanza

Local PLHIV Network / Mtandao wa Ndani

Payment & Account

Malipo na Akaunti • Complete your registration

Create Your Account

Your login email: your email address
Barua pepe yako ya kuingia

Password * / Nenosiri

Confirm Password * / Thibitisha

Registration Summary

Full Name -

Phone -

Region -

Registration Fee / Ada ya Usajili TZS 15,000

First Month Fee / Ada ya Mwezi TZS 3,000

Total Amount / Jumla TZS 18,000

Payment Method * / Njia ya Malipo

📱

M-Pesa

📱

Tigo Pesa

📱

Airtel Money

📱

HaloPesa

🏦

Bank Transfer

💵

Pay Later

Mobile Money Number / Namba ya Simu