AAACC Membership Application

Please be sure to fill in all blanks so that we may best serve your needs and the needs of your family.  Any 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).  After printing this application, please complete all sections and mail the completed application with your cash, check or money order to:

AAACC

P.O. Box 2323

Prince Frederick, MD  20678

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Please identify and describe yourself:

        Name:  ________________________________________________________

        DOB:  ______________

        Sex:  M  /  F

Please provide the following contact information:

        Title:  __________________________________________________

        Organization:  ____________________________________________________

        Street Address:  __________________________________________________

        Street Address (cont.):  _____________________________________________

        City:  ____________________________________________

        State:  _______    Zip Code:  ___________________

        Home Phone:  __________________________

        Work Phone:  ______________________   Fax #:  _______________________

        Cell Phone:  ______________________________

        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:  M  /  F

    Does this child/adult have autism?  Y  /  N

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

DEPENDENT #2

    Name:  ________________________________________________________

    Age:  _________

    Sex:  M  /  F

    Does this child/adult have autism?  Y  /  N

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

DEPENDENT #3

    Name:  ________________________________________________________

    Age:  _________

    Sex:  M  /  F

    Does this child/adult have autism?  Y  /  N

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

DEPENDENT #4

    Name:  ________________________________________________________

    Age:  _________

    Sex:  M  /  F

    Does this child/adult have autism?  Y  /  N

    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?    Y  /  N

Current Marital Status:    Single  /  Married  /  Separated  /  Divorced  /  Widowed

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