Membership

Applicants Details

Under the privacy Act we are obliged to make sure all information you provide is not incorrectly assigned to someone else with the same name. Date of birth provides an initial measure of security so that this does not occur.

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* 1. First Name:

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* 2. Surname:

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* 3. Address:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

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* 4. Email:

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* 5. Phone Number:

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* 6. Date of Birth:

Date / Time

Date

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* 7. Ethnicity (collected for funding purposes)

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* 8. Second Ethnicity:

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* 9. Gender

Male

Female

Other

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* 10. Relationship to Autism

Family/Whanau

Community Professional

Person with ASD

Other

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* 11. Local Branch

Auckland Branch

Bay of Plenty Branch

Canterbury/West Coast Branch

Gisborne Branch

Hawkes Bay Branch

Nelson/Marlborough Branch

Otago Branch

Rotorua Branch

Southland Branch

Taranaki Branch

Taupo Branch

Waikato Branch

Wairarapa Branch

Wellington Branch

Whanganui Branch

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* 12. Email updates

Including updates on Education programmes and other events in your area

Information about making a regular donation or bequest

Family Details - Immediate family, or extended family living with autism

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* 13. 1. Full Name:

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* 14. Date of Birth:

Date / Time

Date

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* 15. Relationship to you

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* 16. Relationship to Autism

Family/Whanau

Community Professional

Person with ASD

Other

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* 17. Ethnicity (collected for funding purposes)

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* 18. 2. Full Name:

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* 19. Date of Birth:

Date / Time

Date

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* 20. Relationship to you

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* 21. Relationship to Autism

Family/Whanau

Community Professional

Person with ASD

Other

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* 1. First Name:

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* 2. Surname:

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* 3. Address:

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* 4. Email:

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* 5. Phone Number:

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* 6. Date of Birth:

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* 7. Ethnicity (collected for funding purposes)

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* 8. Second Ethnicity:

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* 9. Gender

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* 10. Relationship to Autism

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* 11. Local Branch

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* 12. Email updates

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* 13. 1. Full Name:

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* 14. Date of Birth:

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* 15. Relationship to you

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* 16. Relationship to Autism

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* 17. Ethnicity (collected for funding purposes)

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* 18. 2. Full Name:

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* 19. Date of Birth:

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* 20. Relationship to you

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* 21. Relationship to Autism

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* 22. Ethnicity (collected for funding purposes)