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FOCUS ON CHILDREN WITHIN THE AUTISM SPECTRUM INC. (FOCAS)

ABN 38 262 080 94

PO Box 5230, Canning Vale South WA

MEMBERSHIP FORM

PRIMARY OBJECTIVES OF FOCAS:

To create educational & social opportunities for our children & their families.

To provide information and resources for families of children with Autism Spectrum Disorder.

To raise awareness about Autism Spectrum Disorder.

Member Name/s _______________________________________________

Address _______________________________________________

_______________________________________________

Telephone/ Mobile _______________________________________________

Fax _______________________________________________

Email _______________________________________________

OTHER INFORMATION (Optional):

Name of child with ASD:

________________________________________________________

Relationship to child:

________________________________________________________

Date of Birth of child with ASD:

_______________________________________________________

Date of diagnosis & Age at diagnosis:

________________________________________________________

Diagnosis given:

_______________________________________________________

Early Intervention Provider / School currently enrolled:

________________________________________________________

Other interest in children with ASD:

________________________________________________________

I would like to become a member of Focus On Children Within The Autism Spectrum Inc.

Signature ______________________________________

Date ___________________

Please enclose your payment of $10 membership fee

MAKE CHEQUES OR MONEY ORDERS PAYABLE TO:

FOCUS ON CHILDREN WITHIN THE AUTISM SPECTRUM INC.

In the course of its operation Focus On Children Within The Autism Spectrum Inc. may collect personal information about you – for example; name, address, occupation & names of family members (children/spouse). The primary purpose for collecting this information is to enable us to inform you about the activities of FOCAS and to fulfil our responsibility to maintain current and accurate member records of FOCAS. In accordance with the privacy act all information collected by FOCAS is held securely and is accessible only by authorised FOCAS committee members. At any time you may seek access to personal information collected about you. To make a request to access this information, please contact the Secretary in writing.

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