BCC-ASA Membership Form

Membership Form Baltimore - Chesapeake Chapter ASA Membership fee: $10.00 (additional contributions are welcome)
Name:
Address:
City/State/Zip:
Telephone:	Circle one:	Individual with Autism
Child's Name:		Family
Child's Birthday*:		Professional
Child's School/Program*:		Student
Would you prefer to receive the chapter newsletter by: (circle one) U.S. mail? E-mail? Both?	E-mail address:

* optional, but encouraged so that we may plan age related activities and speaker topics.
BCC-ASA does not share information on our members with any other organization.

Make checks payable to BCC-ASA and mail completed form and check to:

Membership Form Baltimore - Chesapeake Chapter ASA

BCC - ASA P.O.Box 10822 Baltimore, MD 21234

Membership Form
Baltimore - Chesapeake Chapter ASA

BCC - ASA
P.O.Box 10822
Baltimore, MD 21234