2025 NZ Alopecia Conference Registration Form

NZ Alopecia Conference & Kids Weekend Registration

19 - 20 April 2025
Alopecians Name*

First NameLast Name
Birth Date*

MonthDayYear
MaleFemaleDon't identify as Male or Female
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Other participants attending:

First NameLast Name
Birth Date

MonthDayYear
Other participants attending:

First NameLast Name
Birth Date

MonthDayYear
Other participants attending:

First NameLast Name
Birth Date

MonthDayYear
Other participants attending:

First NameLast Name
Date of Birthday

MonthDayYear
Other participants attending:

First NameLast Name
Date of Birthday

MonthDayYear
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Format: (000) 000-0000.
Does the participant/participants have any allergies, chronic illness, or medical conditions? If yes, please describe. (please list who has what)*
Are there any dietary requirements? Allergies or fussiness? (please write who has what allergies)*
Yes I would love to joinNo Thanks
How many will be coming to The Blend Bistro & Bar (Casual Dinner)
Daytona Adventure Park - Payment time of entry*
Any other information/questions you might have in regards to Daytona Adventure Park
Any other information we should know? *
I'm happy for photos to be published to social mediaI'm happy for photos to be published to social media if faces are coveredI'd rather not have any photos of me/my child published
Yes I would love to buy one of theseNo ThanksPlease ask me at a later date
Payment Details

Conference cost $45 includes food at the conference.

Those attending dinner at Blend Bar and Bistro and/or Daytona at your own cost.

Please note Daytona are giving a discount for those bookings from NZ Alopecia, voucher to be given at conference.

Please deposit payment to

NZ Alopecia 03-1519-0088306-001

Use your surname as Reference, and code as Conference
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

NZ Alopecia Conference & Kids Weekend Registration