ASEA Online Membership Registration and Renewal | Autism Society of Edmonton Area

Do you want to become an ASEA Member?
Are you an ASEA member who needs to renew their membership?

Then just fill in this online form! After you're done, you'll be taken to a secure PayPal page where you can pay with your credit card. (If you are applying for a free assisted family membership, no payment is necessary.) Once your payment is complete, an ASEA staff member will contact you with your membership/renewal info within 1 business day.

When you become a member the Autism Society of Edmonton Area, you'll

Be able to take advantage of our many programs and services
Receive a copy of Autism Now, ASEA's quarterly publication, four times a year.
Gain access to the special members only section of our web site.
Become a member of a community that has given strength and support to families of individuals with autism for decades.

If you'd like to pay for your membership at the ASEA Office or by cheque, click here.

Only fields marked with asterisks (*) are mandatory, but we ask that both new and renewing members fill in as much information as possible. This will help us to serve you better in the future.

Member Information

Membership Status: *

Member Number:

Type of Membership: *

*ASEA recognizes that some families are unable to afford annual fees. ASEA will consider requests for assisted family membership on a case by case basis. All inquiries will remain confidential.

Primary Member

Title: *

First Name: *

Last Name: *

Occupation/Workplace:

I Am: *

Other:

Company/Organization Name:

Secondary Member

Title:

First Name:

Last Name:

Occupation/Workplace:

Address Line 1: *

Address Line 2:

City: *

Country: *

Province/Territory:

State/Province:

Postal/ZIP Code: *

Primary E-Mail: *

Secondary E-Mail:

Phone

Home: *

Work:

Cell:

About Your Children

Please enter information about your children in any order. You can include children both with and without Autism Spectrum Disorders.

First Child

First Name:

Last Name:

Date of Birth:

School:

Diagnosis 1:

Diagnosis 2:

Diagnosis 3:

Second Child

First Name:

Last Name:

Date of Birth:

School:

Diagnosis 1:

Diagnosis 2:

Diagnosis 3:

Third Child

First Name:

Last Name:

Date of Birth:

School:

Diagnosis 1:

Diagnosis 2:

Diagnosis 3:

I Would Like to Receive ASEA's Quarterly Magazine Autism Now by: *

Do You Want to Volunteer for ASEA?: *

If you select Yes, an ASEA staff member will contact you shortly.

Donating to ASEA

Do You Want to Make An Optional Donation to ASEA?: *

This is in addition to your membership fee.
If you want to donate to ASEA without becoming a member, click here.

Donation Amount: $

E-Mail Canadian Tax Receipt?:

Do you want to receive a tax receipt in your e-mail? Remember that only donations of $25 and over qualify for tax receipts.
Please note that you will only receive a tax receipt for your optional donation, and not for your membership fee.