211 Bronson Ave, Suite 210 Tel: 613-230-6305 Fax: 613-237-4874
Ottawa ON K1R 6H5 www.autismontario.com/ottawa
Date of Birth: E-mail: Phone:
City: Prov: PC:
How did you hear about Autism Ontario – Ottawa Chapter?
What type of volunteer work are you interested in?
What experience do you have with individuals with Autism Spectrum Disorders?
What days and hours are you available to volunteer?
Phone – work: Phone – work:
Name Address Phone
May we share your information with other Autism Ontario members, Regional Support Leaders, etc for volunteer
purposes? O Yes O No
Is there anything else that you would like to tell us about yourself?
Signature of Applicant: Date:
Signature of Guardian, if under 18 years of age: Date: