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ABIQ MEMBERSHIP REGISTRATION FORM
Please print, complete and send this form, together with your cheque or money order made payable to ABIQ, to Autism Behavioural Intervention Queensland (ABIQ) Inc., PO Box 7053 Brendale Q 4500
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Details
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Please complete appropriate amount
(This is an annual membership fee, due each September)
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| Family Members - two adults |
$25.00* (AUS) |
$___________ |
| Family Member - one adult |
$15.00* (AUS) |
$___________ |
| Therapists/Teaching Assistants |
$15.00* (AUS) |
$___________ |
| Professionals |
$25.00* (AUS) |
$___________ |
| Corporate Membership |
Donation |
$___________ |
| Student (#must tick email option below) |
Free of charge |
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| Donation (Donations over $2.00 are tax deductible. ABIQ is a volunteer organisation, and does not receive any government funding to assist in providing much needed information and support. Please consider a donation - every cent counts) |
$___________ |
| *includes GST. |
Total Paid
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$___________
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( It is a legal requirement that ABIQ keep a member register.
Please ensure all applicants names are listed to facilitate correct record keeping.)
Name: __________________________________________________________________________
Address:_________________________________________________________________________
Town: ______________________________ State: ____________ Postcode: _____________
Phone: BH ________________________ AH ____________________________ FAX ______________________________
Email address: _______________________________________________________________________________________
# To help reduce administrative costs your quarterly edition of ABIQ News and general correspondence can be delivered to your email address. Are you happy to do this? _____Yes or _____No
Children involved in an ABA program (if any)
F/M Name: _____________________________________________ Age: __________________
F/M Name: _____________________________________________ Age: __________________
Please detail your relationship to the child/children involved in the ABA program (e.g. parent, teaching assistant, grandparent, teacher etc.) ________________________________________________
How did you become aware of ABIQ? ________________________________________________
Please note:
1. The information provided on this form may be used for statistical purposes.
2. Individual details will not be disclosed without prior written consent.
3. Annual membership should be renewed every September before the AGM.
4. Only members who are financial are eligible to vote at the Annual General Meeting.
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