Autism LifeSpan Membership Application 2011

* Indicates required field for electronic submission.

Date:
Please enroll me in the following membership:
Individual $40.00                   Local Business Supporter $50.00
Family $50.00                        Local Supporter $25.00
Student $30.00                      Donation $

Membership dues include the Autism LifeSpan quarterly newsletter and unlimited access to our Lending Library.

*Name(s):

*Address:

*City: *State: * Zip:

*Phone (home): (work):

Email: Occupation (optional)

Please check the category that best describes you:

Parent  Individual with Autism   Family Member   Educator 
 
Service Provider   Medical Professional   Other

Payment Information:
Visa     Mastercard Cash Check (please make payable to Autism LifeSpan)  

*Name on Card

*Card # * Exp. Date (mo/yr)

Thank you for your support!
Autism LifeSpan is a 501(c)(3) non-profit Corporation. All membership and donations are tax deductible.