AFRICARE-WHICO

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[FORMS]

REGISTRATION FORM
Title:
First Name:
Last Name:
Sex:	Male Female		Marital Status:	Single Married Divorced
Your Age:			Spouse's Name:
Number of Children:			Ages of Children:
Company Name:
Occupation:
Your Mailing Address:			Phone/Fax with Area Code:
			E-mail Address:
City:			If outside of U.S.:
State:
Postal Code:
Which issues are especially important to you?
For Nigerians: in addition, please provide the following information:
Geographical Region:		State:
Local Government Area:		Ward/Unit:
Party Affiliation:	(optional)
Comments:	.

AFRICARE-WHICO - Providing Healthcare System that is:
People-Centered, Accessible, Affordable, Equitable, Quality and Sustainable to the rural medically underserved poor communities in Africa

General Health Care
Children's Health
Women's Health
Elderly Care
Education
Adoption
Medicine