I want to become an
AuSM MEMBER!
AuSM Membership Form 2380 Wycliff St. #102 St. Paul, MN 55114 651.647.1083 •
[email protected] www.ausm.org
Send or fax completed form with payment to AuSM or join online at www.ausm.org. AuSM Fax: 651.642.1230
First Name ___________________________________ Last Name ____________________________________ E-Mail ____________________________________________________________________________________ Address ___________________________________________________________________________________ City ________________________________________ State ________________Zip ______________________ Phone Number _______________________________ AuSM Membership Status q New Member q Renewing Member Please check category that best describes you: q Parent q Family Member q Service Provider q Individual with Autism q Educator q Medical Professional q Other Membership Category (Please select one) q Household: $60 (includes 2 adults and children or grandchildren under 21) q Educator/Professional: $40 (individual membership for autism professionals) q Person with ASD: $20 (individual membership for adults over 21 with ASD diagnosis) q Non-Profit: $150 (includes memberships for employees) q Corporate: $350 (includes memberships for employees) In order to better meet your Household Membership needs, please indicate the age(s) of the individual(s) with ASD. __________________________________ Please let us know how you heard about AuSM. _________________________________________________ Form of Payment (Payable to AuSM) Total ___________________________ Check # _________________________ Credit Card: q Visa q MasterCard q Discover Card # ______________________________________________ Expiration _____________ CVV __________ Signature ______________________________________________________
childhood
adolescence
transition
adulthood