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:

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The information and resources on the Families for Effective Autism Treatment of Rhode Island web site and Listerv (Site) are for educational and informational purposes only. Information provided through the Site should not be used as a substitute for care by a qualified Developmental Pediatrician, Pediatric Neurologist, Behavioral Psychologist, Behavior Analyst, Speech and Language Pathologist, Attorney, or other appropriate professional.

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