Membership Form
National membership fees/dues have increased. Local chapter fees have remained the same. Note changes below.

To join the Texas Gulf Coast Chapter of the Autism Society of America, please print or copy this form and return it completed with your dues to: TGCC-ASA, P.O. Box 57865, Webster, TX 77598, Attention: Membership

Please make checks payable to: Texas Gulf Coast Chapter - ASA

Membership is from the date you join to the same date the following year.

Name: __________________________________________________
Address: _____________________________________________________
City: _________________________________ State: __________ Zip: ___________
Home Phone: ____________________ Business Phone: ____________________
e-Mail1: _______________________________ e-Mail2: ______________________________
Profession or Association: ______________________________________________
If a parent or guardian, please provide the following:
Child's Name: _________________________________ Birth Date: _______________________
School or District: ______________________________________________________
Disabilities: ____________________________________________________________
[  ] I grant permission to use my child's photograph in this newsletter or on the ASA Web site taken from group events and functions.
Status (Please check): New _____ Renewal _____ Newsletter Only_____
Please check your affiliation: Dues:
___ Family $50 (National Dues $40, Local $10)
___ Individual $40 (National Dues $30, Local $10)
___ College/Student $25 (National Dues $15, Local $10)
___ Professional $110 (National Dues $100, Local $10)
___ International $65 (National Dues $50, Local $15)
___ Newsletter only $15
Please submit this form with your check for renewals as well. Dues are to be paid every calendar year to keep your membership active.

Your newsletter will automatically be sent via e-mail (if listed above). Five issues of The Beacon are published per calendar year. Often, two issues are combined into one publication.