Bermuda AUTISM Support & Education
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Welcome to BASE Bermuda AUTISM Support & Education
 
Kindly fill out the details below for online membership or simply click here to download the form manually &
send it to our mailing address
 
MEMBERSHIP FORM
REGISTERED CHARITY # 590
   
Member Name: *
Mailing Address:
Contact Numbers: Home: *
Work:
E-Mail: *
   
Parent Professional: (Please tick one) Dr OT PT SLP
Aide- Teacher
Other
 
PARENT PLEASE COMPLETE
Children (diagnosed and siblings)
 
Name Birth date Sex Diagnosis
/ /
D   M   Y
/ /
D   M   Y
/ /
D   M   Y
/ /
D   M   Y
 
PROFESSIONALS PLEASE COMPLETE
 
Would you like your name and number posted on our general membership list?
(This list would be available to ALL members)
Yes No
   
Would you like your name and number posted on our professionals list?
(This list would be available only to the professionals in our membership and the executive committee)
Yes No
 
AREAS OF INTEREST
 
Speech Physical therapy Occupational therapy Sensory integration
 
Behavioral therapy Education Diet
Other
 
 
Membership dues are $25 per year. Send completed membership form with dues to:
P.O. Box FL 93, Flatts FL BX, Bermuda
 
 

BASE Bermuda AUTISM Support & Education