AAC-VA Membership Form


1.  Complete and print the form below
2.  Enclose $20 membership fee and mail to:  AAC-VA, P.O.Box 2687, Merrifield, VA 22116

(ALL CHECKS PAYABLE TO AAC-VA)

* First Name:
* Last Name:

 

  
* Address:
* City:
* State:
* Zip Code:

 

 

* Daytime Telephone:
--
* Evening Telephone:
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* Email:

 

 

 *Do you have a family member with autism?                                             

*If applicable, specify relationship to individual with autism:                      

*Why are you joining AAC-VA?   

 Learn about autism treatments      Advocate for autism        Looking for support group         Help set autism policy    

*Would you be willing to volunteer for AAC-VA events?