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:

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* 4. Email:

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* 5. Phone Number:

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* 6. Date of Birth:

Date / Time

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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

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

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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:

Date / Time

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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)

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