Charity Champion Sign Up

First name (required)

Surname (required)

Email address (required)

Confirm email address (required)

Contact telephone number (required)

Postal address including postcode (required)

Age (required)

16-1718-2425-3435-4445-5455-6465-7475 and over

What is your connection to alopecia? (required)

I have alopecia (hair loss)I am supporting a loved one with alopeciaThrough my work, I engage with people who have alopecia I have no connection to alopecia but have been inspired to get involved

What type of alopecia do you have? (required)

Alopecia AreataAlopecia TotalisAlopecia UniversalisAndrogenetic Alopecia (pattern hair loss)Frontal Fibrosing AlopeciaLichen PlanopilarisTelogen EffluviumTraction AlopeciaCentral Centrifugal Cicatricial AlopeciaOtherI don’t know what type of hair loss I haveI do not have hair loss

Ethnicity

To which gender do you most identify?

Would you like an Alopecia UK t-shirt? (It will be sent to you once you have set up an online fundraising page OR notified us of your fundraising plans - [email protected]) (required)

Yes pleaseNo thank you

Preferred T-Shirt Size (Subject to Availability) (required)

No t-shirt neededAdult SmallAdult MediumAdult LargeAdult X LargeAdult XX Large