Autism Society of America
Texas Gulf Coast Chapter
pertaining to Autism/Pervasive Developmental Disorders (PDD) 		Membership
Application

To join the Texas Gulf Coast Chapter of the Autism Society of America, please print this form and return it completed with your dues to: TGCC-ASA, 17047 El Camino Real #100, Houston,Tx.77058, Attention: Membership

Parent Name ______________________________________________
Address _________________________________________________
City____________________________ State _____ Zip ___________
Home Phone ________________ Business Phone ________________
Status (Please check): New ____ Renewal ____ Newsletter Only____
Please check
your affiliation:		 Dues:
___ Family $45 (National Dues $35, Local $10)
___ Individual $35 (National Dues $25, Local $10)
___ College/Student $27.50 (National Dues $17.50, Local $10)
___ Professional $35 (National Dues $25, Local $10)
___ International $45 (National Dues $30, Local $15)
___ Newsletter only $15
If a parent or guardian, please provide the following:
Child's Name _________________________ Birth Date __________
School or District _________________________________________
Disabilities ______________________________________________
Membership is from the date you join to the same date the following year.
Please make checks payable to:
Texas Gulf Coast Chapter - ASA
Autism Society of America
Texas Gulf Coast Chapter
17047 El Camino Real #100
Houston,Tx.77058

Hosted on the WWW by:Kathy Waites
E-mail: kwaites@phoenix.net