Name:

Address:

Phone:

E-mail:

Age of Child with Autism:

School of Attendance:

School District:

Are you a current member? Yes   No

Would you like to receive mailings? Yes   No

What topics of information are you interested in?

How did you hear about us?

Are you clients of Kern Regional Center? Yes   No

Can we contact you through email or by phone? Email  Phone Do not contact

Other Comments/Questions: