Register for Eating Disorders and Autism

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Phone*

If you require accommodations (captions, etc.) please specify here. These requests must be made at least two weeks in advance of the event.

Registration rates

Please select your registration rate.*

Non-member ($59.99)
AuSM Member or joining today ($49.99)
Individual with ASD ($39.99)

I am joining AuSM or renewing my membership today.*

Membership Category*

Household: $60
Individual: $40
Autistic Individual: $20
Non-Profit Agency/Company: $150
For-Profit Company: $350

Household Members

Please share some information about the other members of your household. If you have more than 6 members in your household, please call 651.647.1083 or e-mail info@ausm.org to provide information about all members of your household.

Please select number of members in your household membership including the participant listed on this form.*

Name of second member in household.*

First Last

Contact information is the same as participant's listed above.

Yes

Address of second member in household*

Street Address Address Line 2 City State ZIP Code

E-mail of second member in household*

Date of birth of second member in household*

Name of third member in household.*

First Last

Contact information is the same as participant's listed above.

Yes

Address of third member in household*

Street Address Address Line 2 City State ZIP Code

E-mail of third member in household*

Date of birth of third member in household*

Name of fourth member in household*

First Last

Contact information is the same as participant's listed above.

Yes

Address of fourth member in household*

Street Address Address Line 2 City State ZIP Code

E-mail of fourth member in household*

Date of birth of fourth member in household*

Name of fifth member in household*

First Last

Contact information is the same as participant's listed above.

Yes

Address of fifth member in household*

Street Address Address Line 2 City State ZIP Code

E-mail of fifth member in household*

Date of birth of fifth member in household*

Name of sixth member in household*

First Last

Contact information is the same as participant's listed above.

Yes

Address of sixth member in household*

Street Address Address Line 2 City State ZIP Code

E-mail of sixth member in household*

Date of birth of sixth member in household*

Payment

Please check with your county case manager to learn if your select class can be paid for under the Community Access for Disability Inclusion (CADI); Brain Injury (BI); Community Alternative Care (CAC); Consumer Support Grant (CSG); Family Support Grant (FSG); or Developmental Disability (DD) waivers. By registering for an AuSM class, you agree to pay in full any amount not covered by the third party payer. Scholarship applications are now closed.

Total

$0.00

If you have a coupon code, please enter it here.

I would like to apply for a scholarship.*

Yes
No

Please select your payment type*

Pay now by credit card
Share third party payer information to be invoiced

Donating to AuSM helps support programs like this. If you'd like to make a donation, enter the amount here.

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

CAPTCHA

Scholarship Application

The following questions will help AuSM determine your eligibility for a scholarship to attend this event. The information you provide will guide our decision-making process. Scholarship applications will close on November 14, and an AuSM staff member will contact you shortly afterward with next steps. To qualify for a scholarship, you must be a Minnesota resident.

Are you an AuSM member?*

Yes
No

AuSM aims to make its programs accessible to underserved groups. In order to help us meet this goal, please share the groups to which you identify (as you are comfortable).

I am an autistic adult.
I am part of a racial minority.
I am part of an ethnic minority.
I am LGBTQIA.
I have a disability other than autism.
I live in a rural area.
Other

If other, please specify.

How many people, including yourself, are in your household?*

If you have a circumstance you would like AuSM to take into account in this scholarship consideration, please explain below.

Have you received financial assistance to participate in AuSM programs this year?*

Yes, an AuSM scholarship
Yes, third-party assistance
No

Third Party Payment

By completing this form, you agree to pay in full any amount not covered by the Third Party Payer.

Third Party Payer Organization Name*

Third Party Payer Contact Name*

First Last

Third Party Payer Address*

Street Address Address Line 2 City State ZIP Code

Third Party Payer E-mail*

Third Party Payer Phone*

Register for Eating Disorders and Autism

Eating Disorders and Autism Registration

Registration rates

Household Members

Payment

Scholarship Application

Third Party Payment