AUTREAT REGISTRATION FORM

Name                                                                    
Age
(if under 18)
Days Attending            
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

OPTIONAL additional donation: ____________
Donations will be used for scholarships and overall program enhancements.

Total enclosed: ___________________
 
If alternate materials format is needed, please indicate:

Braille __

Large Print__

Tape  __

Disk  ___

If accessible lodging is needed, please indicate:
___ Wheelchair-accessible room
___Roll-in Shower
___Can walk but have trouble with stairs





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 15, 2005

Registration Fees
The sums below are in US dollars.

EARLY REGISTRATION DISCOUNT
RATES BEFORE JUNE 1, 2005
 
 
Member
 
Nonmember
Fee Category
Per day
or
4-day total
 
Per day
or
4-day total
A Adults with full-time jobs(1)
90
 
335
 
97
 
355
B Children 12 and under(2)
55
 
200
 
60
 
220
C Teens 13-17(2)
75
 
280
 
80
 
300
D Adults without full-time jobs
75
 
280
 
80
 
300
E Adults living on disability or public assistance
45
 
170
 
50
 
190
F Full-time support people(3)
40
 
150
 
45
 
170

RATES AFTER JUNE 1, 2005
 
 
Member
 
Nonmember
Fee Category
Per day
or
4-day total
 
Per day
or
4-day total
A Adults with full-time jobs(1)
92.50
 
345
 
99.50
 
365
B Children 12 and under(2)
57.50
 
210
 
62.50
 
230
C Teens 13-17(2)
77.50
 
290
 
82.50
 
310
D Adults without full-time jobs
77.50
 
290
 
82.50
 
310
E Adults living on disability or public assistance
47.50
 
180
 
52.50
 
200
F Full-time support people(3)
42.50
 
160
 
47.50
 
180

Note 1: We realize that not all full-time jobs are high paying. If you have a full-time job but can't afford this rate, add a note explaining this, and you may register at the rate for adults without full-time jobs.

Note 2: The rate for children and teens includes a supervised activity program for all children under 18. Staff:child ratio is approximately 1:6. If your child needs more support than this, please bring an aide for your child, or contact ANI about hiring extra staff for an additional fee.

Note 3: This rate is for people who are attending Autreat for the purpose of providing support for a disabled person who could not participate without a FULL-TIME helper. Examples are personal care attendants for adults and 1:1 aides for children.

Work Shift Rebate

Adults and teens paying for the full 4 days, meals, and overnights may earn a $20 work rebate. Pay the full cost when registering. The rebate will be given upon completion of a work shift during Autreat. Full-time support people are not eligible for work shift rebates; their rate is set $20 lower than anyone else's because we don't expect them to have time to do a work shift while also providing full-time support for another person.

Partial Registration Options

Full registration includes lodging Monday night through Thursday night, and meals from Monday supper through Friday lunch.
Per-day registration includes one night's lodging, three meals, and 24 hours of participation in Autreat activities.

If attending days only, but making your own lodging arrangements off-site: Subtract $12 per person per day. Please indicate “Days only” on registration form.

If making your own meal arrangements and not eating meals provided by Autreat: Subtract $15 per person per day. Please indicate “No meals” on registration form.

Room Assignment Options

Two or three people will be assigned to each residence hall room. Additional bunks can be moved in to allow up to four people per room, upon request. There is no extra charge for this, but it must be requested in advance. Private rooms may be reserved for an additional fee, on a first-come first-served basis, as space allows.