Autism-Asperger Association of Calvert County, Inc.

 

 

AAACC

 

 

 

A non-profit 501(c)(3) organization offering information, support and assistance to Southern Maryland families facing autism spectrum disorders

BECOME  A  MEMBER

 

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Membership Application

Thank you for your interest in, and support of the AAACC.

 

Please be sure to fill in all blanks so that we may best serve your needs and the needs of your family.

 

All information provided within this application is for AAACC use only and will not be shared with any outside party without the express permission of applicant(s).

 

Please identify and describe yourself:

Name
Date of Birth
Sex Male Female

Please provide the following contact information:

Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL

What is the best time & method to contact you? 

Tell us more about your family.  Please provide information about your dependents below:

Dependent #1

Name
Age
Sex Male Female

What school does this child attend?


Dependent #2

Name
Age
Sex Male Female

What school does this child attend?


Dependent #3

Name
Age
Sex Male Female

What school does this child attend?


Dependent #4

Name
Age
Sex Male Female

What school does this child attend?


The AAACC offers a parent-to-parent referral program to its members. Many parents have found respite & fellowship through this program.

May we share your contact information with other members of the AAACC for this purpose only?  Yes No

 

Current Marital Status: 

Please check your interest in participating in the following AAACC activities or committees:

Fundraising                  Membership                   Publicity                    Website                    
Special Events               Lending Library              Advocacy                     Hospitality/Goodwill       
Newsletter                   Meeting Planner              Public Education             Organization/Agency Liaison

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Deborah S. Ursiny
Copyright © AAACC. All rights reserved.
Revised: June 05, 2008