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1-800-7-ASTHMA
info@aafa.org
AAFA
Support Group Information

Group Name:

Date:

State:

Area Served
(State, County, or Metro Area):

 

Group Type (please mark at least one of the following in each category):

Focus:

Asthma
Allergies
Food allergies

 

Audience:

Adolescents
Adults
Parents
All Ages

 

Please provide your group’s contact information the way you would like it available on the AAFA website searchable database:

 

Leader(s):

Meeting Location:

Contact number:

E-mail:

Website:

 

Please provide leader and medical advisor contact information:

 

Leader (Required):

Address:

Phone number:

Email:

 

Co-Leader (Optional):

Address:

Phone number:

Email:

 

Primary Medical Advisor (Required):

Medical Specialty:

Address:

Phone Number:

Fax Number:

Email Address:

 

Secondary Medical Advisor (Optional):

Medical Specialty:

Address:

Phone Number:

Fax Number:

Email Address:

 

Please provide contact information for at least 5 group members:

 

Name:

Address:

Phone Number:

Email address:

 

Name:

Address:

Phone Number:

Email address:

 

Name:

Address:

Phone Number:

Email address:

 

Name:

Address:

Phone Number:

Email address:

 

Name:

Address:

Phone Number:

Email address:

 

 
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