COACHELLA VALLEY AUTISM SOCIETY OF AMERICA
Please use the following application for a new membership, renewal of membership, or newsletter
(Husband & Wife's first names if family membership)
(Area code) (Area Code)
EMAIL:_____________________________________________ Please initial if you give permission
for CVASA to email you, instead of using regular mail. Newsletter will still be sent via regular mail.
___________ (Please initial)
Please check one: You May NOT_____ You MAY____ give my phone number to other members
of CVASA and add my name to the membership directory.
Please check type of membership below:
Individual membership: $40.00___ $30.00 will be sent to ASA, Autism Society of America &
$3.00 to ASC, Autism Society of California (Newsletter
Family membership: $50.00___ $40.00 will be sent to ASA, Autism Society of America &
$4.00 to ASC, Autism Society of California (Newsletter
Local Newsletter Only $10.00___ 1 year of Newsletter, as well as all other mailings
Please check one: New Membership:___ Membership renewal:___
Please check one: Person with Autism/Family Member:___ Professional:___
Please advise age of person with Autism___
Please send check to: Coachella Valley ASA, P. O. Box 11052, Palm Desert, CA 92255-1052
We now also accept Visa/MasterCard for your convenience.