National Ataxia Summit Registration Form

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Ataxia Awareness Society (AAS) is holding a National Ataxia Summit on 8th and 9th October 2022 at Indore.

Registration Fee
3000 INR ( 1 Patient + 1 Caretaker)

AAS Bank Details :
Ataxia Awareness Society
Bank of Baroda, R. S. S. Nagar Branch, Indore
Ac no. 38870200000225
IFSC code BARB0HIGMIG

For a⁸

ny queries, Contact :

9826472333

9179854927

Name of Patient: *

Option 1

Clear selection

Resdential Address *

Contact No: *

Emergency Contact No: *

Age: *

Gender: *

Male

Female

Others

Type of assistance required : *

Walker

Stick

Wheelchair

Not Required

Required

Any current medical conditions mentioned below:

Diabetes

Heart problem

How many Caretakers are accompanied by you? *

none

If any, provide Caretaker's details

Name of Caretaker

Relationship with Patient

Contact No of Caretaker

Fees details - *

paid (please send screenshot of transaction at 09826472333)

not paid

Option 3

Other:

Required

Submit

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