Membership Registration

I would like to become a member of Alopecia Areata Germany / Switzerland

Salutation

Mrs

First name (Required)

Surname(Required)

Address(Required)

Postal code / City (Required)

Date of birth (Required)

Phone(Required)

E-mail address (Required)

I have read and agree to the Statutes »

I want to sign up for the newsletter

I hereby accept the transmission of my data

Required Year Contribution...(Required)

Note: Minimum fee CHF 69.00 / reduced CHF 34.00 (children, students, apprentices, unemployed with certificate)

Comment (optional)

Please repeat the characters (Required)

This field should be left blank

Please wait...