Membership

Applicants Details

The personal information collected from you on this form is required by Autism New Zealand for the purposes of providing our services. It may also be used for statistical purposes in a way that will not identify the individual. The information collected will be held securely in our Dynamics 365 system and Autism New Zealand will respect the confidentiality of the information collected.

Providing some information is optional however if you choose not to enter your name or contact details, we may be unable to provide our services.

You have the right to ask for a copy of any personal information we hold about you, and to ask for it to be corrected if you think it is wrong. If you’d like to ask for a copy of your information, or to have it corrected, please contact us at lee.patrick@autismnz.org.nz, or 04 803 3501, or 20 Sydney St, Petone, 5012.

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/Whānau

Community Professional

Autistic person

Other

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* 11. Local Branch

Auckland Branch

Bay of Plenty Branch

Canterbury/West Coast Branch

Gisborne Branch

Hawkes Bay Branch

Manawatū Branch

Nelson/Marlborough Branch

Otago Branch

Rotorua Branch

Southland Branch

Taranaki Branch

Taupō 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 who is autistic

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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

Autistic person

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/Whānau

Community Professional

Autistic person

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)