COAST-TO-COAST MEMBER ACTIVITY FORM
To obtain Sun Safety Toolkit from WDS office

Participating members - Be sure to also visit:
www.playsafeinthesun.org/coast2coast
for downloadable tools and online resources.
Form Date: 

MEMBER INFORMATION:
Member Name: *REQUIRED
E-Mail Address: *REQUIRED
Address:
City:
State:
Zip:
Phone Number: *REQUIRED
Cellular Phone:
Fax:

Are you currently a WDS Member (or Pending Member): *REQUIRED    Yes    No..( WDS Membership Required - Membership Details Online HERE )
    • There are volunteer opportunities for non-members, too! Please call 877-WDS-ROSE to learn more.

ACTIVITY INFORMATION:
Outreach activity planned (please describe) *REQUIRED


Location:
Date:
Time:
Expected number of participants:
Age range of participants:

Address for shipping the Sun Safety Toolkit (if different from address above—if not, write SAME)
Shipping Address:
Shipping City:
Shipping State:
Shipping Zip:

NOTE: A courtesy box of broad-spectrum sunscreen will be furnished to you by the Campaign’s supporter, La Roche-Posay. This package will be shipped to you separately from the educational materials provided by the WDS. Please let us know if there is a different shipping address where you would like to receive the sunscreen.

ADDITIONAL COMMENTS:


     


                


For further information about Women’s Dermatologic Society, visit:
www.womensderm.org
www.playsafeinthesun.org

Contact (General Inquiries): WDS Home Office at 1-877-WDS-ROSE
Contact (Media Inquiries): Nancy FitzGerald, Director of Communications at (760) 333-9296

The Women's Dermatologic Society supports the careers and professional development of women dermatologists. The mission of the Women’s Dermatologic Society is to help women in dermatology achieve their greatest personal and professional potential by striving to: foster, promote, and support women’s issues in dermatology; identify, train, and recognize women leaders in dermatology; and provide a forum for developing relationships.

Women’s Dermatologic Society
700 N Fairfax St., Suite 510, Alexandria, VA 22314
Toll-Free: 1-877-WDS-ROSE (937-7673) | Tel: (571) 527-3115 | Fax: (571) 527-3105
eMail: wds@womensderm.org | www.playsafeinthesun.org