Participant Name(s): Parents name:
Home Phone #: Mobile Phone #:
Put a tick Workshop Date & Time Cost
Holiday Program Wednesday 19th – Friday 21st January 2011 $700
Initial planning meeting This is only a requirement for new families to Autism
Summary report - $140 Only for families that are interested $140
FaHCSIA Funded To book your child please send a $70 booking fee and a copy of your letter ‘Introduction to Early Intervention
(Booking Deposit) Services Helping Children with Autism package from FaHCSIA to confirm your place. This booking deposit
will only be refunded to you on the first day of program.
Non-Funded Full payment is required for non-funded families/services 3 weeks prior to start date.
Account Name: Autism Action
BSB: 033 135 Account Number: 292195
Please quote Workshop Reference Number and your Surname with payment
Your application will be processed promptly and a confirmation receipt posted to you. For all admin and workshop queries please
contact Anne Robins on 03 9899 7816 or firstname.lastname@example.org
Please Note. Secure your place in these small group workshops with prompt payment. Limited places available. GST is included in
all prices. Privacy: The collection of these details is primarily so that we can register you for this event. The information (excluding
payment details) will be stored in the Autism Action database and may be used for future marketing of Autism Action workshops and
Cancellation Policy. To receive a full refund please cancel your attendance at least 1 week prior to the workshops date.
Cancellations received with less than 1 week before hand will not be refunded.
Disclaimer: Fees are subject to change without notification.
www.autismaction.com.au 03 9899 7816 44 Birdwood Street
Box Hill South VIC 3128