Prize Form

Basic information

Initiative name

i.e. Mosquito nets for all

Official initiative website

First name

Last name

Position/role in the initative

i.e. Founder

How many people are in your initiative

If you are a one-person operation, don’t be discouraged! You are fully entitled to join this competition! We are looking for the quality of your initiative, not how many people are in it.

When was your initiative set up

mm/dd/yy

Phone

Street

City

State/Province

Postal code

Country

Your initiative

How will your initiative combat dengue? What makes it stand out?

How does it integrate the vaccine as an holistic plan to combat dengue?

What inspired you (the founder) to do this?

What is a key highlight or milestone you would like to share?

What challenges do you anticipate and how do you plan to overcome them?

Could you share your logo?

Could you share any pictures of your initiative in action?

Link to a picture gallery

How many people will you be able to help?

How can you multiply the impact of your initiative with $10,000?

Do you have anything else you would like to share about your initiative?

References

Please provide 2 references we can contact to confirm that you and your initiative are real.

Reference #1

First name

Last name

Position

Organization

Phone

Reference #2

First name

Last name

Position

Organization

Phone

Terms and conditions

You can check the terms ad conditions here.

I agree with the terms and conditions

Yes

By joining the contest, I understand that Break Dengue may communicate about me and my initiative on their social media channels, website, and other offline channels/collaterals.

Yes

€10,000 Prize: Help us to Break Dengue

Basic information

Your initiative

References

Reference #1

Reference #2

Terms and conditions