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About
News
Contact
Membership
Donate
Resources
What is Autism
Social Narratives
Resource Directory
Scholarships and Waivers
Accessing ASD Supports and Services in Minnesota
COVID-19 Resources
AuSM Shop
Information and Resources
Therapy
Meet Our Therapists
Ask the Therapist
Support Groups
Make an Appointment
ACCS Publications
Events
Steps for Autism in Minnesota
Autism Acceptance Month
State Autism Conference
AuSM Golf Classic
Autistic Community Summit
Puzzle Competition
Give to the Max Day
Accessing ASD Supports and Services in Minnesota
Education
AuSM Skillshops
Classes
Training
Social Skills Classes
Workshops
Accessing ASD Supports and Services in Minnesota
AuSM Celebrates Interdependence
Multicultural Initiatives
Camps
Hand in Hand
Discovery
Wahode Day Camp
Camp Questions and Answers
Registration and Packets
Work at Camp
Get Involved
Volunteer
Fundraise for AuSM
Reach the Community
Policy Advocacy
Become a Presenter
Research Studies
Education
Training
Autism Certification
Direct Support Certification Registration
Direct Support Certification Registration
2021-2022 Autism Direct Support Certification
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?
*
Membership Status
*
AuSM Member or Renewing/Purchasing Membership Today
Non-Member
If you are uncertain of your membership status, please email Maura at mmcdonald@ausm.org for confirmation.
Registration
Please select the session you would like to attend.
*
Fall 2022 (Sept. 9, 16, 13, 30, Oct. 7, 2022)
Please check a category that best describes you.
*
Job Coach
Support Staff
Personal Care Attendant (PCA)
Educational Aide
Direct Support Professional
Group Home Staff
Day Training and Habilitation Professional
Someone who works directly with individuals with ASD
EIDBI provider
Other
I am registering a second participant.
*
Yes
No
Name of second participant
*
First
Last
E-mail of second participant
*
Phone of second participant
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
By registering for the Event, I hereby consent that the Autism Society of Minnesota (AuSM) may videotape, interview, film, or photograph me to illustrate the activities of AuSM. I also grant AuSM or its designee permission to use and/or publish said video, interview, film, or photograph and further waive any right I may have to inspect and/or approve the finished product prior to publication. The materials may include, but are not limited to, newsletters, annual reports, brochures, advertisements, websites, social media sites, training materials, and/or posters. Further, I agree that I shall receive no compensation of any kind for the use of my words or likeness. I discharge AuSM from any and all claims which may arise from use of any video, interview, film, and/or photograph.
*
Check box for photo/video release permission.
Demographic Information
Please specify your gender
*
Female
Male
Other
Prefer not to answer
Please select your ethnicity.
*
African-American
Asian/Pacific Islander
Caucasian
Hispanic or Latino
Hmong
Native American or American Indian
Somali
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
I am purchasing or renewing my membership today.
*
Yes
No
AuSM Membership Status
*
New Member
Renewing Member
Membership Category
*
Household (two adults and children or grandchildren under 21)
Educator/Professional
Person with ASD (individual membership for adults over 21 with ASD diagnosis)
Non-Profit
Corporate
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 you.
A Household membership includes two adults, plus children or grandchildren under 21.
1
2
3
4
5
6
Name of second member in household
*
First
Last
Contact information is the same as main contact.
Yes
Address
*
Street Address of second member
Address Line 2 of second member
City of second member
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State/Province of second member
ZIP/Postal Code of second member
E-mail of second member
*
Gender of second member
*
Female
Male
Other
Prefer not to answer
Date of Birth of second member
*
MM slash DD slash YYYY
Name of third member in household
*
First
Last
Contact information is the same as main contact.
Yes
Address
*
Street Address of third member
Address Line 2 of third member
City of third member
State/Province of third member
ZIP/Postal Code of third member
E-mail of third member
*
Gender of third member
*
Female
Male
Other
Prefer not to answer
Date of Birth of third member
*
MM slash DD slash YYYY
Name of fourth member in household
*
First
Last
Contact information is the same as main contact.
Yes
E-mail of fourth member
*
Address
*
Street Address of fourth member
Address Line 2 of fourth member
City of fourth member
State/Province of fourth member
ZIP/Postal Code of fourth member
Gender of fourth member
*
Female
Male
Other
Prefer not to answer
Date of Birth of fourth member
*
MM slash DD slash YYYY
Name of fifth member in household
*
First
Last
Contact information is the same as main contact.
Yes
Address
*
Street Address of fifth member
Address Line 2 of fifth member
City of fifth member
State/Province of fifth member
ZIP/Postal Code of fifth member
E-mail of fifth member
*
Gender of fifth member
*
Female
Male
Other
Prefer not to answer
Date of Birth of fifth member
*
MM slash DD slash YYYY
Name of sixth member in household
*
First
Last
Contact information is the same as main contact.
Yes
Address
*
Street Address of sixth member
Address Line 2 of sixth member
City of sixth member
State/Province of sixth member
ZIP/Postal Code of sixth member
E-mail of sixth member
*
Gender of sixth member
*
Female
Male
Other
Prefer not to answer
Date of Birth of sixth member
*
MM slash DD slash YYYY
Employees
Employees receive a membership through corporate and non-profit memberships. If you would like to specify employees who will be using the membership or who would like to receive information about AuSM, please add their information here. If you have more than 6 employees to specify, please call 651.647.1083 or e-mail info@ausm.org to provide information.
Please select the number of employees whose information you would like to enter.
0
1
2
3
4
5
6
Employee 1
*
First
Last
E-mail of Employee 1
*
Phone of Employee 1
*
Employee 2
*
First
Last
E-mail of Employee 2
*
Phone of Employee 2
*
Employee 3
First
Last
E-mail of Employee 3
*
Phone of Employee 3
*
Employee 4
*
First
Last
E-mail of Employee 4
*
Phone of Employee 4
*
Employee 5
*
First
Last
E-mail of Employee 5
*
Phone of Employee 5
*
Employee 6
*
First
Last
E-mail of Employee 6
*
Phone of Employee 6
*
Payment
Would you like to add a donation to the Autism Society of Minnesota?
Yes
No
Donation Amount:
*
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 E-mail
*
Third Party Payer Contact Phone
*
My billing address is the same as my mailing address.
Yes
Billing Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Credit Card
*
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
Expiration Date
Security Code
Cardholder Name
CAPTCHA
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