Screening Program
Coordinator Registration
ACAAI Nationwide Asthma
Screening Program
 

 

I am an ACAAI-member allergist and would like to coordinate
an asthma screening program in my community. I will submit
a date and location for my screening by August 31.

Coordinating Allergist
Address
City
State
Zip
Office phone
Office fax
E-Mail

Note: Although multiple allergists may participate,
a single ACAAI member must be designated as
the official coordinator for each screening.

Alternatively, you may open this form as a PDF, print it out,
and fax the completed form to: (312) 558-5425