Autism Network International Subscription Form Name _________________________________ Birthdate _____ Address ____________________________________________________ City, State, ZIP _______________________________________________ Phone number ___________________ Interests __________________________________________________ __________________________________________________________ Circle one: AUTISTIC PERSON FAMILY MEMBER _________________ __ informally or self-diagnosed (Relationship) __ formally diagnosed by a professional) "COUSIN" _________________________________________ (Person with a documented developmental neurological abnormality having a significant overlap with autistic characteristics: for example, hydrocephalus, Williams syndrome, Tourette syndrome) TEACHER _______________ OTHER _________________ (Age and level of students) __ 1996 subscription ___1994-95 issues ___1993 issues Enclose subscription fee of $15 per set ($20 overseas), in U.S. funds, and return to ANI, P.O. Box 35448, Syracuse, New York 13235-5448. PENPAL DIRECTORY INFORMATION (For autistic people and cousins only): Do you want your name included in the directory? ___ Yes ___ No Do you want your address included in the directory? ___ Yes ___ No Do you want your birthdate included in the directory? ___ Yes ___ No Do you want your interests included in the directory? ___ Yes ___ No Are you able to use the directory and to carry on private correspondence independently, or do you need help? Independent use of the directory means that you are able to keep the directory in a private place, look up information in it, write letters, address envelopes, and read personal letters that other people send you, without needing another person to help you. ___ I can correspond independently ___ I will use a helper to correspond (Parents, teachers, facilitators, and other service providers: Do not sign up an autistic person for the penpal directory unless the person communicates that he or she wants to participate. ANI believes that social connections need to be freely chosen.) (Optional) ___ I use facilitated communication (You are not required to disclose this information. It is a voluntary option so that FC users wishing to contact other FC users can identify each other.) If you wish to receive a copy of the directory, please read and sign: I am an autistic person or a "cousin," and I wish to receive a copy of the ANI directory. I agree not to share my copy of the directory with anyone. I agree not to give out information about anyone listed in the directory unless that person gives me permission to do so. Signature _________________________