___Student $15 ___Individual $30 ___Family $40 ___Outside USA $50  __Professional $100 ___Agency $500 ___Life $1,500

___I am a new member ___I am renewing membership   

Name(s): ______________________________________________________________________________

Address: ______________________________________________________________________________

Phone: (h)_________________________ (w)________________________ (c)_______________________

Email 1:__________________________________ Email 2:_____________________________________

Employer or professional background:____________________________________________________________________________

I am a: ___ Parent ___ Family Member ___ Service Provider ___ Educator ___ Medical Professional

___Individual with Autism ___ Other (please describe):___________________________________________

___Yes! Please add my name to the mailing list to receive ASD’S newsletter The Sun.
(This is for families who do not receive The Sun through Delaware Autism Program Distribution only please.)

My membership fee is……………………………………………..$___________________
I would also like to contribute this amount directly to ASD …..$___________________

Total amount enclosed (add both amounts)……………………..$___________________

Date:______________________________

Please make your checks payable to the (ASD) and send the check and application to
ASD, 5572 Kirkwood Highway, Wilmington, DE 19808.  All membership fees and contributions are tax deductible.