ALOPECIA
SUPPORT GROUP - SYDNEY
PO BOX 142
EASTWOOD NSW 2122
Membership includes 4 newsletters a year, increased access to the website and
a complimentary information pack.
Please enroll me with the Support Group for the financial year 2008 / 2009
I am a sufferer
of:
Areata
Totalis
Universalis
Other
Parent of sufferer Child's Name......................
Supporter
Surname: Mr / Mrs / Miss / Ms ………………………………………….……...
First Name: ………………………………
Address :.......................................................................
.....................................................................................................................................
Tel. No: ……………………………………………. Post Code: ………………....
E-mail address …………………………………………………………….………...
Date of Birth (of sufferer) …… / …… / …… Male Female
No of years / months as a sufferer ………………………............
Money order / cheque enclosed made payable to:-
Alopecia
Support Group - Sydney $..................
(No cash through mail please.)
Signature:
………………………………………….Date: ……………………….....