REGISTRATION FORM


Names________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________
(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)_________________________________________

E-mail______________________________________________

_____Autistic person
_____Person with another developmental disability
_____Family member
_____Friend
_____Professional (educator or clinician)

Please remit payment, including child care fees if applicable, to:

        Autism Network International
        P.O. Box 35448
        Syracuse NY 13235-5448