Registration Form
Indy for Autism Sunday May 4th, 2008 9a.m. to 12 noon
Please return by mail or fax before April 21, 2008 Autism Ontario, Niagara Region 60 James Street Suite 404 St. Catharines, ON L2R 7E7 Phone: 905-682-2776 Fax: 905-682-5609
60 James Street Suite 404 St. Catharines, ON L2R 7E7
Phone: 905-682-2776 Fax: 905-682-5609 Email: autismsocietyniagara@on.aibn.com
5th Annual Indy for Autism
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The ASD Puzzle What is Autism Spectrum Disorder?
Autism Spectrum Disorder (ASD) is a complex neurological disorder that is characterized by impairments in communication & social interaction.
Organization’s Name Contact Name _______________________________________ Address & Postal Code _______________________________________
Niagara Go Karts Niagara Falls, ON
Autism is estimated to occur in as many as 1 in every 165 individuals There is no known cure for Autism With appropriate early on going intervention, many children greatly improve.
Ph: ________________________________ Fax________________________________ E-Mail______________________________
Autism Ontario- Niagara’s Key Services
Programs designed specifically to meet the needs of individuals with ASD and their families including two year-round programs and summer camps. A Resource Centre, provincial Autism magazine, and local newsletters Guest speakers at membership meetings and mutual support Family Funding Bursary
Lets’ Go Racing…..
Sun. May 4th, 2008
9 a.m. to 12 noon
Payment
□ Cheque made payable to: ASO Niagara □ Visa MasterCard Cash
Name on Card __________________________
Enjoy three hours of continuous motion
Challenge rival teams A go-kart for each team BBQ lunch, refreshments, t-shirts and team plaques
Card# _____________________________ Expiry Date _________________________ Authorized Signature __________________ ___________________________________ Our Mission
“To ensure that each individual with Autism Spectrum Disorder is provided the means to achieve quality of life as a respected member of society”
Trophies for The team that raises the most dollars The best theme team The best time on a special timed lap The last-but-not-least team
Indy for Autism
When: Sunday May 4th, 2008 9 a.m. to 12 noon Where: Niagara Go-Kart, Niagara Falls, ON Cost: Minimum donation of $1000. per team
Of special note: Make a team flag (out of cloth or vinyl) no larger than 8” by 10” ready to attach to your car. It is advisable to bring eye protection (sunglasses) & gloves. If you wish to have children on your team there are family cars that they can ride in, youth must be 14yrs & 5ft. to drive the formula 1 car or 10yrs and 4ft.6ins. to drive the family car.
TEAM NAME_______________________________________________________ The form below is for those organizations that are gathering pledges in lieu of or in conjunction with a team sponsorship. Name Address City Postal Phone # Amount Code Pledged
Amount Collected
Receipts will automatically be issued for donations of $20.00 or more.