Community Member Registration

First Name

Please enter your first name

Last Name

Please enter your last name

ID Number

Please enter a valid 13-digit ID number

Date of Birth

Please enter your date of birth

Gender

Please select your gender

Population Group

Please select your population group

Latitude

Not available - Location access required

Longitude

Not available - Location access required

Accuracy

Not available - Location access required

Location map will appear here
once location access is granted

Village/Area Name

Please select your village/area

Stand/House Number

Please enter your stand or house number

Street Name

Section/Zone

Ward Number

Phone Number

Please enter a valid phone number

Email Address

Please enter a valid email address

Alternative Phone Number

Number of People in Household

Household includes children under 18

Household includes person(s) with disability

I consent to participate in community assessments and agree to the processing of my personal information for community development purposes

Location Access Required