Autism Society of New Brunswick

                                                        Membership Sign-up Form


                                           Sign up for:

Membership
Autism NB News List
Autism Support Group List
Parent to Parent List

                        Name:________________________________________________

                        Child's Name:________________________Age:_______________

                        Address:______________________________________________

                        City:_____________________________State/Prov:____________

                        Country:________________________Zip/Post Code:___________

                        Phone:________________________________________________

                        Email:_________________________________________________

                                   Please forward the completed form along with a cheque or money-order to:

                                               Autism Society of New Brunswick
                                                         P.O. Box 1493 Station A
                                                    Fredericton, NB    E3B 5G2

                                              You will be sent a membership card upon receipt of your fee.

                                   All information will be maintained by ASNB and will remain confidential.