Name _________________________________ Birthdate _____
Address ____________________________________________________
City, State, ZIP _______________________________________________
Phone number ___________________
Interests __________________________________________________
__________________________________________________________
Circle one:
AUTISTIC PERSON FAMILY MEMBER _________________
__ informally or
self-diagnosed
(Relationship)
__ formally diagnosed (by a professional)
"COUSIN" _________________________________________
(Person with a documented developmental
neurological abnormality
having a significant overlap with autistic characteristics: for
example, hydrocephalus, Williams syndrome, Tourette syndrome)
TEACHER _______________ OTHER _________________
(Age and level of students)
Enclose subscription fee of $15 ($20
overseas), in U.S. funds, and
return to ANI, P.O. Box 35448, Syracuse, New York
13235-5448.
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