ANIRIDIA FOUNDATION INTERNATIONAL
MEMBERSHIP FORM

Please fill out the following form as completely as possible.
Required fields are highlighted and MUST contain information.

PERSONAL INFORMATION:

I am a (check all that apply)
(* At least one must be checked)
I have aniridia. My birthdate is:
Parent of a child with aniridia
Relative of a person with aniridia Relationship:
I do not have Aniridia, but am a teacher with students who have Aniridia.
I do not have Aniridia, but am a physician with patients who have Aniridia.
I do not have Aniridia, but I am a researcher.

First Name:
Last Name:
Gender:
Male Female 		Occupation:
Spouse Name:
Spouse Occupation:


CHILDREN:

Children with aniridia:
(* If you state a name, you must also specify a gender and a birthdate) (* Gender and birthdates are only used for statistical purposes)
Childs Name:
Gender:
Male Female 		Birthday:
Childs Name:
Gender:
Male Female 		Birthday:
Childs Name:
Gender:
Male Female 		Birthday:
Childs Name:
Gender:
Male Female 		Birthday:

Children WITHOUT aniridia:
(* Birthdates are optional, but helpful)
Childs Name:
Gender:
Male Female 		Birthday:
Childs Name:
Gender:
Male Female 		Birthday:
Childs Name:
Gender:
Male Female 		Birthday:
Childs Name:
Gender:
Male Female 		Birthday:


CONTACT INFORMATION:

(Please make sure you keep all this information current so that you will continue to receive information, member benefits and new research) Help us hold down costs by contacting us when your information below changes. All returned mail, emails or phone numbers will result in membership termination and an administrative fee will be assessed to re-join.
I understand that I need to keep my information current.

Address:
Address 2nd line:
Apartment:
City:
State:
Zipcode:
Country:
 
Phone number:
Cell Phone:
Email Address:

FREE NEWSLETTER:

As a member of Aniridia Foundation International, you will receive a free quarterly newsletter called "Eye on Aniridia" via the mail provding your address is kept current. Issues come out in March, June, September and December. If you do not receive the MAILED or EMAILED version by the end of the month, please contact our office. IF YOU LIVE OUTSIDE THE USA, OR YOU USE COMPUTER MAGNIFICATION OR READER SOFTWARE, PLEASE MARK APPROPRIATE BOX AND KEEP YOUR EMAIL ADDRESS CURRENT. For email delivery, please add news@aniridia.net to your address book and check your spam folder for missing newsletters. Donations are always appreciated and are tax deductible.

Large print via postal mail
Email in PDF format (opens with Adobe Acrobat Reader)
I use a screen reader program and need the newsletter emailed to me in MICROSOFT WORD format.

I am unable to use the computer, pleaase send my newsletter on an audio cassette tape

I am unable to use the computer, pleaase send my newsletter on a CD

Please note that cassettes or CD"S being mailed outside the USA will require an annual fee to cover additional costs.



FAMILY ACCESS:

If you would also like a spouse or relative added to the members only area, please provide their information below.

First Name:
Last Name:
 
Relationship to you:
Their Email Address:
 
Address:
Address 2nd line:
Apartment:
City:
State:
Zipcode:
Country:
   
Send them the newsletter:
Yes No 		   


DOCTOR INFORMATION:

Please enter your doctor's information below:

First Name:
Last Name:
 
Designation:
MD OD PhD 		Specialty:
 
Address:
Address 2nd line:
Suite:
City:
State:
Zipcode:
Country:
   
Phone number:
Email Address:
 

It is helpful to keep your doctor up to date on information about Aniridia and it's associated conditions. We have a special area on our website for physicians and researchers, plus a semi-annual newsletter, "ANIRIDIA INSIGHT", written just for them by their peers and colleagues. If they would like to receive this and have access to this special area, please provide complete information below. We can only accept completed submissions.

By Mail (let the staff know that this is NOT unsolicited mail)
Via email PDF (this email will only be used by us and not shared with anyone)


BEING AN ACTIVE MEMBER:

I would like to be on a committee to help with:
(* check all boxes that apply)

The medical conferences and socials
Corporate Fundraising, United Way Payroll Deduction Program
Grant writing (we will teach you but strong writing skills are encouraged)
HOPE Scholarship Fund (Helping Other PEople)
Help with website (keeping current, researching for new articles, etc)
Newsletter staff (article writing, gathering, advertising, etc)
Fundraising events (planning, executing, charity auctions, golf tournaments)
Graphics and Printing (various projects for those in that industry)
Volunteer Database (creating database of volunteers, skills and contacting - this includes community volunteers not only members)
I can not be a volunteer at this time, however, I would like to be an annual donor (you may set this up on a monthly, quarterly or yearly basis on our donation page LINK with your credit card or by contacting your bank's bill pay, or by choosing ANIRIDIA FOUNDATION INTERNATIONAL thorugh your company's UNITED WAY payroll deduction plan...please feel free to ask us to help with this option)

We understand not all people have time to volunteer. And if you choose to be financially supportive instead...thank you. Just remember, even a couple hours a month, can really help.


WELCOME TO ANIRIDIA FOUNDATION INTERNATIONAL
Once your member form is processed, you will receive a membership packet with information, our brochures, your member ID and password for the online Members Only area, and the International Aniridia Medical Registry questionnaire. This registry questionnaire is very important to gaining data so that we can have researchers have something to study...only this way we will move towards a cure. Please participate in this Phase I project. For more information, see your newsletter, the website (www.aniridia.net) or call us at 901-448-2380.