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First Name: Last Name:
Spouse Name:

Occupation:
 Gender:
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I am a (check all that apply)
*At least one must be checked
Parent of a child with aniridia
I have aniridia. My birthday is: (month/day/year)
I am a teacher with aniridia students. Please suggest the parents join also.
I am a doctor with aniridia patients. Send me (#) brochure packets
I am a researcher. I am researching

Children with aniridia:
*If you state a name, you must also specify a birthday.
Name:
Name:
Name: 		Birthdate:
Birthdate:
Birthdate:

Children WITHOUT aniridia:


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.
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If you would like a spouse or relative added to the members only area also please provide the emails below.
Name (first, last): Relationship to you:
Their email: Do they want the newsletter:
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MEMBERSHIP

I would like my FREE quarterly newsletter "Eye on Aniridia" by (check one):

Large print via postal mail
Email in PDF format (can open with Adobe Acrobat Reader)
Audio Cassette via postal mail

Donations to help with costs of this service are greatly appreciated.


Our doctors would like to receive "Aniridia InSight", a newsletter for physicians and researchers, twice a year.

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)

Please enter your doctor's information below
First Name:
 Last Name:
Designation:
MD OD PhD		 Specialty:
Address:
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BEING AN ACTIVE MEMBER

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 (raising money to help needy people attend the medical conferences)
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)

We understand not all people have time to volunteer. However, with a couple hours a week, it can really help. If you find that you can not volunteer your time, there are other ways to help like making a yearly or monthly donation (by check, credit card or monthly debit by clicking HERE) OR providing a personal contact name of your friend, colleague or family member’s business or foundation to contact for support, OR hosting a fundraising event (dinner party, cocktail, garage sale, ideas are endless)

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.