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PASA Membership Form

Purchase Area Chaptern of the Autism Society of America Membership Form
Zip code____________________
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:__________________
School System_____________________
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.
Phone number:______________________

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:

Susan Byram
144 Valley Rd.
Paducah, KY 42001