Become a Member or Renew

Name*

First Last

Address*

Street Address City State ZIP Code

E-mail*

Phone*

Date of Birth*

Employer/Company

How did you hear about AuSM?*

Secondary Contact Name

First Last

Secondary Contact E-mail

Secondary Contact Employer

Demographic Information

Please specify your gender*

Female
Male
Other
Prefer not to answer

Please select your ethnicity.*

Select your household annual income.*

Membership

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)
Agency Non-Profit
Corporation

Total

$0.00

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 of second member*

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 of third member*

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 of fourth member*

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 of fifth member*

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 of sixth member*

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

How would you like to pay?*

Third party payer
Pay now

Third Party Organization Name*

Third Party Contact Name*

First Last

Third Party Contact E-mail*

Third Party Contact Phone*

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

Yes
No

Donation Amount:*

Credit Card

American Express

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MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Become a Member or Renew

Become an AuSM Member

Demographic Information

Membership

Household Members

Employees

Payment