AASA Children's Events - Register Interest
Name of Parents: *
Address: *
Best Contact Number: *
Your E-mail Address: *
Child 1:
Please enter name of child suffering of Alopecia
Date of Birth:
Is your Child?
Male
Female
Child 2:
Please enter name of child suffering of alopecia
Date of Birth:
Is your Child?
Male
Female
Activities Interested in Participating in:
Picnics
Movies
Bowling
Luna Park
Bike Riding
Indoor Play Center
Roller Blading
Hiking
Coastal Day Trips
Other Suggestions:
Industry Contacts:
Such as Village, indoor play centres who can discount their facilities/donate time etc.
Name:
Phone Number:
E-mail:
May we contact them directly?
Yes
No I prefer to
Further Comments/Suggestions:
Child Willing to help on day?
Act as a big brother/sister to a younger child suffering of Alopecia
Yes
No
Please confirm you are an AASA Member
YES
Type the following:
For security purposes, please type the letters in the image.