AuSM Skillshops 2021-2022 Registration

AuSM's education team will provide you with the link to the virtual AuSM Skillshop(s) for which you register prior to the start. Virtual AuSM Skillshops will be available in real-time only and will not be accessible after they have taken place. Please visit www.ausm.org for more information.

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

E-mail*

Phone*

Demographic Information

This information is used for grants and reporting.

Please specify participant's ethnicity.*

African-American
Asian/Pacific Islander
Caucasian
Hispanic or Latino
Hmong
Native American or American Indian
Somali
Other
Prefer not to answer

Please specify participant's gender.*

Female
Male
Other
Prefer not to answer

Select your household annual income.*

Less than $10,000
$10,000-$30,000
$30,000-$50,000
$50,000-$70,000
$70,000-$90,000
$90,000-$120,000
$120,000-$150,000
$150,000+
Prefer not to answer

Membership Status

Membership Status*

AuSM Member or Joining Today
Non-Member
Individual with ASD or Student

Select the AuSM Skillshop(s) you would like to attend virtually.

A list of AuSM Skillshops will appear once you have selected your membership status.

Please select the AuSM Skillshop(s) you would like to attend virtually.*

Oct. 26, 2021: Self-Management and Self-Regulation
Nov. 9, 2021: Strategies for Successful Employment
Dec. 14, 2021: Guardianship: Do We Need It?
Jan. 11, 2022: Supported Decision Making
Jan. 25, 2022: Creating Autistic-Friendly Social Spaces
Feb. 8, 2022: Video Modeling: Why It Is Useful and How to Create One

Please select the AuSM Skillshop(s) you would like to attend virtually.*

Oct. 26, 2021: Self-Management and Self-Regulation
Nov. 9, 2021: Strategies for Successful Employment
Dec. 14, 2021: Guardianship: Do We Need It?
Jan. 11, 2022: Supported Decision Making
Jan. 25, 2022: Creating Autistic-Friendly Social Spaces
Feb. 8, 2022: Video Modeling: Why It Is Useful and How to Create One

Please select the AuSM Skillshop(s) you would like to attend virtually.*

Oct. 26, 2021: Self-Management and Self-Regulation
Nov. 9, 2021: Strategies for Successful Employment
Dec. 14, 2021: Guardianship: Do We Need It?
Jan. 11, 2022: Supported Decision Making
Jan. 25, 2022: Creating Autistic-Friendly Social Spaces
Feb. 8, 2022: Video Modeling: Why It Is Useful and How to Create One

Total

$0.00

I am joining AuSM or renewing my AuSM membership today.*

Yes
No

Joining AuSM today: which category best describes you?

New Member
Renewing Member

Select your membership category.

Individual with ASD ($20)
Household $60)

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 yourself

Name of second member in household

First Last

Contact info for second member in household is the same as address 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 info for third member in household is the same as address 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 info for fourth member in household is the same as address 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 info for fifth member in household is the same as address 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 info for sixth member in household is the same as address 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.

I would like to apply for a scholarship.*

Yes
No

How would you like to pay?*

Pay now by credit card
Third party payer

Total

$0.00

Billing address is the same as mailing address

Yes

Billing Address*

Street Address Address Line 2 City State ZIP Code

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Third Party Payer Organization*

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.

Contact at Third Party Payer*

First Last

Third Party Payer Phone*

Third Party Payer Address*

Street Address Address Line 2 City State ZIP Code

Third Party Payer E-mail*

CAPTCHA

Scholarship Application

The following questions will help AuSM determine if you are eligible for a scholarship for this event. The information you provide informs this decision. You will be contacted by an AuSM staff member once we receive your application to let you know if your application has been approved and how to proceed.

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, live 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