Inform, Influence, Innovate Together Conference 2021 Registration

Name*

First Last

Address*

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

County*

E-mail*

Phone*

How did you hear about the Inform, Influence, Innovate Together virtual autism conference?*

If you require accommodations for participating in this virtual conference, please specify here. These requests must be made at least two weeks in advance of the conference.

I am a...*

Family Member
Individual with ASD/Autistic
Professional
Teacher
Therapist
Other

If other please specify

Demographic Information

Please select your ethnicity.*

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

Select your household annual income.*

Gender*

Female
Male
Other
Prefer not to answer

Registration

I am a...*

AuSM Member or Joining Today
Non-Member
Individual with ASD

Total

$0.00

I am joining AuSM or renewing my membership today.*

Membership Category*

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*

VIP Session with Temple Grandin

On Friday, April 23 from 6:30-8:30 p.m., the Autism Societies of Minnesota and Greater Wisconsin will host a VIP session with Temple Grandin. This exclusive session will be limited to 30 participants. Participants will be able to submit a question to Dr. Grandin, take a virtual photo with Dr. Grandin, and will be sent a signed copy of Dr. Grandin's book, Thinking in Pictures.

VIP Session with Temple Grandin

I would like to add the Temple Grandin VIP session to my registration.

Yes

Shipping Address*

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

Payment

I would like to apply for a scholarship.*

Yes
No

Are you paying through a third party payer or purchase order?*

If you plan to pay today with a credit card, even as a third party payer, please select no.

Yes
No

All online transactions include a convenience fee of $5. Please check this box to accept.*

Convenience Fee

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Total

$0.00

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Third Party Payment/Purchase Order Information

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

Third Party Payer/PO Organization Name*

Third Party Payer/PO Contact Name*

First Last

If you know your PO number, please enter it here.

Third Party Payer/PO Address*

Street Address Address Line 2 City State ZIP Code

Third Party Payer/PO E-mail*

Third Party Payer/PO Phone*

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. Scholarship applications are due by March 12, 2021.

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

At times AuSM offers partial scholarships in order to support more participants. If you were offered a partial scholarship, how much would you be able to contribute towards your registration fee?*

Inform, Influence, Innovate Together Conference 2021 Registration

Inform, Influence, Innovate Together 2021 Registration

Demographic Information

Registration

Household Members

VIP Session with Temple Grandin

Payment

Third Party Payment/Purchase Order Information

Scholarship Application