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

           Does this child/adult have autism? --- Yes No  

           What school does this child/adult attend, if any? 

DEPENDENT #2

Name
Age
Sex	Male Female

           Does this child/adult have autism? --- Yes No  

           What school does this child/adult attend, if any? 

DEPENDENT #3

Name
Age
Sex	Male Female

           Does this child/adult have autism? --- Yes No  

 What school does this child/adult attend, if any? 

DEPENDENT #4

Name
Age
Sex	Male Female

           Does this child/adult have autism? --- Yes No

           What school does this child/adult attend, if any? 

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:  Single Married Separated Divorced Do not wish to specify

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