MEMBERSHIP

BECOME A MEMBER OF AUTISM SOCIETY ACADIANA

If you would like to become a member of Autism Society Acadiana, please submit the form below electronically. If you choose not to become a member, please remember you are still, always welcome at any local support group meeting just to receive information and support. However quite a few of our events are reserved for our members and families only, so please do consider becoming a member of Autism Society Acadiana.

PRINT YOUR MEMBERSHIP FORM HERE

Membership Form

Membership, Postal Mailing and Email Lists

Name:*

Mailing Address:*

City:*

Zip:*

Phone Number:*

Email Address:*

Please check all that apply: You are: a person with an Autism Spectrum Disorder(ASD): You are: a person with an Autism Spectrum Disorder(ASD)

Or have a child or family member w/ ASD: A child or Family Member

Or Medical Professional: Medical Professional
Educator: Educator
Other (college student, etc.) Other(college student, etc.)

Name, age, and birth date of the individual with an autism spectrum disorder(ASD):

Diagnosed by: (Professional’s Name & Contact Information address and phone number)

Membership Benefits Include:

Eligibility to attend events offered solely for Autism Society Acadiana members and their families.
Eligibility to apply for stipends for your child to access recreational and leisure activities and programs.
Eligibility to apply for an educational stipend to cover your registration fee to a conference or seminar that
will enhance your knowledge, skills, and ability to more effectively raise your loved one with autism.
Email and US postal notification of autism-related events, activities, workshops and conferences.
A support system that provides comfort and information to families living with autism.
Information and referrals to local and state resources.
Membership in a growing organization which serves families and individuals living with autism spectrum
disorders.

For Office Use Only

Date Received: ____________________

Added to Membership List: __________

Added to Constant Contact__________

Added to Send Out Cards: ___________

*Note: Membership applications are also available at our office.