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?*

Membership Status*

AuSM Member or Renewing/Purchasing Membership Today
Non-Member

Registration

Please select the session you would like to attend.*

Certification Winter Session (Saturdays, Jan 16-30)

Please check a category that best describes you.*

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 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.*

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.

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 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*

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*

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*

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*

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*

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.

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

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 State ZIP Code

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 if you are eligible for a scholarship for this class. The information you provide informs this decision.

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

Direct Support Certification Registration

2020-2021 Autism Direct Support Certification

Registration

Demographic Information

Membership

Household Members

Employees

Payment

Scholarship Application