Membership Renewal ? YES   NO

Member Name:     
Mailing Address:   
Parish:                           Postal Code:
Telephone: (Home)                            (Work) 
E-mail:                 
Parent   Professional: (Please tick one) Dr OT PT SLP Aide Teacher Other

PARENT PLEASE COMPLETE

Children (diagnosed and siblings)
Name                                           Birth date (DD/MM/YY)                Sex                      Diagnosis

PROFESSIONALS PLEASE COMPLETE

 
Would you like your name and number posted on our general membership list? YES   NO
(This list would be available to ALL members)

Would you like your name and number posted on our professionals list? YES   NO
(This list would be available only to the professionals in our membership and the executive committee)

AREAS OF INTEREST