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Email is our main communication forum on gneral information, events & research updates.

Your information may be used to:

• provide you with information;
• report to government or other funding bodies on how funding is used;
• process your donation and provide a receipt;
• respond to your enquiry.

It may also be used for any other purpose for which it was requested and which has been advised to.

Registry Form:

Your Name*

Your Email Address*

Phone Number

Address

Suburb*

State*

Select OneNSWVICQLDSATASWANTACT

Post Code

Gender*

Select OneMaleFemale

Year of Birth*

Are you a sufferer of Alopecia?*

Select OneYesNo

If yes, please tick which category

Alopecia Areata  Alopecia Totalis  Alopecia Universalis  Androgenetic  Cicatricial Alopecia  Perinaevoid Alopecia Areata  Alopecia Areata Barbae  Other

Does any member of your family have Alopecia (If Yes, Please tick the relationship)

Sibling  Cousin  Parent  Grandparent  Aunt/Uncle  Child  Self

Can your image be used in marketing?*

Select OneYes No

Do you want to be contacted regarding research trials for your category?*

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Do you want to be notified of upcoming events?*

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Would you like to be contacted regarding volunteer assistance needed at events?*

Select OneYesNo

Please provide a brief description in what area you would like to help i.e Man booth, Mail outs, Donation Collection

How did you find out about AAAF

Dr. / Dermatologist  Internet  Event  Friend / Referral  Advertising  Other

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