Direct Support Certification Registration

Name*

First Last

Address*

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

E-mail*

Phone*

Employer/Company

How did you hear about Direct Support Certification?

Registration

Please select the session you would like to attend.*

ASD Direct Support Certification Spring 2025
ASD Direct Support Certification Summer 2025

Please check a category that best describes you.*

Demographic Information

Please specify your gender*

Female
Male
Other
Prefer not to answer

Please select your ethnicity.*

African-American
Asian/Pacific Islander
Hispanic or Latino
Hmong
Native American or American Indian
Somali
White
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

Payment

By registering for an AuSM class, you agree to pay in full any amount not covered by the third party payer. You may also apply for a scholarship in this section.

Would you like to add a donation to the Autism Society of Minnesota?

Yes
No

Donation Amount:*

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

Total

$0.00

I would like to apply for a scholarship.*

Yes
No

How would you like to pay?*

Third party payer
Pay now

Third Party Payer Organization Name*

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

Third Party Payer Contact Name*

First Last

Third Party Payer Contact Email*

Third Party Payer Contact Phone*

My billing address is the same as my 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

Scholarship Application

The following questions will help AuSM determine if you are eligible for a scholarship for this class. 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

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