Registration Form

Please Print this form, fill it out, and mail it to the address specified below with payment.

Name

Age (if under 18)

Days attending (specify which day(s), or "All")

Fee category (A-F)

(Please list names of all family members who will attend, and ages of any children under 18)

Address_____________________________________

City/State/Zip________________________________

Phone (day)__________________________________

Phone (night)_________________________________

Email_______________________________________

ANI member household? ___ yes ____ no

(If one person in the household is an ANI member, then everyone in the household is eligible for the ANI member rate.)

If no, would you like to join? ________

Add $15 (for residents of North America)
or $20 (for all other countries) to total.

Total enclosed: _______________

Please remit payment, in U.S. dollars, to:

Autism Network International

P.O. Box 35448

Syracuse, NY 13235-5448

REGISTRATION MUST BE RECEIVED BY JUNE 10, 2002

If alternate materials format is needed, please indicate:

Braille __

Large Print __

Tape __

Disk ___

Upon receipt of your registration, you will be sent a packet containing additional information including directions, a map to the camp, and menu information.