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ANIRIDIA FOUNDATION INTERNATIONAL
TEACHER FORM

If you experience problems with submitting this form, please email the Website programmer with specific details of the problem.

Teachers, You must fill out this form completely. AFI will setup an account for you to use for future visits upon verifying the information which you submit.

YOUR PERSONAL INFORMATION:

My First Name:
My Last Name:
My Address:
Address 2nd line:
Apartment:
City:
State:
OR
Region:
OR
Zipcode:
Country:
My Phone number:
My Cell Phone:
My Personal Email Address:
My School Use Email Address:


SCHOOL INFORMATION

What grade levels do you teach?
I am a:
Other:
What school/university do you teach at?
This school is part of the
School District
Facility Address:
Address 2nd line:
Facility City:
State:
OR
Region:
OR
Zipcode:
Country:
Facility Phone:
Facility Website:

Superintendant or Special Education Supervisoor name:
First:
Last:
Their Address:
Address 2nd line:
City:
State:
OR
Region:
OR
Zipcode:
Country:
Phone:
Email address:


OTHER INFORMATION:

I have aniridia or WAGR students
Are their parents involved in Aniridia Foundation International?
Please let your parents know that joining Aniridia Foundation International is a great way for them to meet other families, learn from experts in the medical field and researchers, and receive the FREE "Eye on Aniridia" newsletter. Membership is free to all Aniridia families. Click here to download membership form to give them.
I would like to speak with your teacher / education specialists
I would like to have a presentation done at our school: Yes No
I would be willing to help spread the word and information about Aniridia Foundation International to surrounding schools or districts


ADDITIONAL COMMMENTS:

Additonal specific comments, questions or what information you would like to see in this area.


     
 




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