Purchase Area Chaptern of the Autism Society of America Membership Form
Status of ASA membership: Individual___ Family___ Not a member (wish to be on PASA mailing list only)___
For Professional Members: Profession:____________________
Place of Employment____________________________
For Parents/Relatives of Individuals with Autism:
Child’s Name:__________________________ Date of Birth:__________________
As parents, sometimes it is nice to talk to someone who can understand how
you are feeling. We include phone numbers on our mailing list so that we
can reach out to each other. These numbers are to be held in confidence
and your participation is, of course, optional.
Purchase Area Chapter of the Autism Society of America is a non-profit,
tax-exempt chapter of the Autism Society of America. We do not require dues.
Donations are welcome and should be sent along with this form to: