Join us as Volunteer

Please enrol me as Volunteer : Full time / Part time / Occasional

Full Time
Part Time
Occasional
Full Name (in Capital Letters): Father's Name / Husband's Name: Mother's Name (Optional): DOB: Sex: Qualification: Occupation: Email: Contact Nos.: Mobile No.: State:
Ph.No. (Residence / Office): Address: How Would you like to support AAS:


Register as Member

Please enrol me as : Patron / Life member / Annual Member

Life Member
Annual Member
Patron
Full Name (in Capital Letters):

Father's Name / Husband's Name:
Mother's Name (Optional):
DOB:
Sex:
Qualification:
Occupation:
Email:
Contact Nos.:
Mobile No.:
Ph.No. (Residence / Office):
State:
Address: Any Message for us (Optional):

Fee Structure: Patron – 12,000/- , Life Member – 6,000/- , Annual Member – 600/-.


Mode of Payment:


  1. At Our Bank, (For Details, Click Here.)
  2. Crossed cheque/ DD drawn in favour of Ataxia Awareness Society,Indore
  3. Cash



Join us as Patient

Please enrol me as : Ataxia Patient

Full Name (in Capital Letters): Father's Name / Husband's Name: Care Taker Name: DOB: Sex: Qualification: Occupation: Email: Patient Contact No.: Care taker Contact No.: State:
Address: Type of Ataxia: Confirmation of type of ataxia through genetic testing (Yes/No): Name of Testing Lab: Under treatment of:

Note: Membership fee Rs.600/- is optional for Ataxia patients.


  1. At Our Bank, (For Details, Click Here.)
  2. Crossed cheque/ DD drawn in favour of Ataxia Awareness Society,Indore
  3. Cash



Note : Fees payment is optional for Ataxia patients

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Ataxia Awareness Society

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