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CENTRAL INDIANA CHAPTER – AUTISM SOCIETY OF AMERICA

Membership Enrollment

Joining this Chapter also includes membership in the Autism Society of America.

  You will receive the Chapter newsletter and the Autism Society of America Advocate six times per year.

(Last Name)                                                     (First Name)                                  (Spouse)

(Address)

(City)                                                                (State)                                            (Zip)

(Area Code) (Phone Number)                         (E-Mail)                                         (County)

New Rates as of February 1, 2004:

I am a :     (   ) Parent or Guardian

                                My child’s current school or program_____________________________________________

                        Child’s name ____________________________________  Birthdate ____________________

                  (   ) Relative or Friend

                  (   ) Student at____________________________________________________________________

                  (   ) Teacher or Professional at ______________________________________________________

I will allow my name to be used as a referral to a parent of a child or adult with Autism? 

Yes ____No___

May we contact you for assistance with one meeting or event?  Yes_____________No_________________

May we contact you for assistance with a committee?

Yes_____________________No__________________

Please mail completed form with check to:             

(payable to: Central Indiana Chapter of ASA)

Central Indiana Chapter - ASA

P.O. Box 50534

Indianapolis, IN  46250