On-Line FEAT/RI Membership Application

*Denotes required fields.

Date:

New Member:     Renewal

Select Membership type:
Parent/Family Member/Student/TA = $35.00
Professional Individual = $50.00
Professional Agency Group = $150.00

Full Name*:

Street Address:
City:   State:   Zip Code:

Home Telephone:   Work Phone:
Fax:   Email*:

Relationship to Autism:
Parent:
Relative: Relation:
Professional: Type:
Other: Describe:

Child’s Name (optional):
Child’s Birthday/age (optional):

Agency Affiliation/ABA Provider:

Please indicate any programs/ideas you would like to see FEAT/RI develop:



Select your payment method (continues on next page after application is submitted):

I will me making using the PayPal online payment system.

I will be mailing a check for payment.

Click the Submit button, below, to continue your application: