WALK FOR AUTISM RESEARCH REGISTRATION

TITLE *

FIRST NAME *

SURNAME *

First name

ADDRESS *

POSTCODE: *

EMAIL *

TELEPHONE *

FAX

MOBILE

HOW WOULD YOU LIKE TO REGISTER? *

I would like to walk as an individual I would like to form a team I would just like information at this time

HOW MANY PEOPLE WILL BE WALKING IN TOTAL? *

NAME OF COMPANY (IF APPLICABLE)

HOW MUCH DO YOU HOPE TO RAISE? (£s) *

AUTISM RELATIONSHIP
(the following person in my life has an autism spectrum disorder):

N/A My child My grandchild My niece / nephew A family member A friend's family member A co-worker's family member I work with/educate those touched by autism Myself I do not personally know anyone touched by autism spectrum disorder Other

OTHER RELATIONSHIP

WOULD YOU LIKE TO BE ON OUR MAILING LIST? *

Please select Yes, I would like to be on your mailing list No, a member of my household is already on the mailing list No, I would not like to be put on your mailing list

HOW DID YOU HEAR ABOUT AUTISM SPEAKS? *

WOULD YOU LIKE TO VOLUNTEER TO HELP ON THE DAY?

Please select Yes. Please send me details No, I am unable to volunteer

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