Out-of-State Indiana Resource Center for Autism Reporter Subscription Form

Indiana Resource Center for Autism
REPORTER
Subscription and Release Form
2008-2009 Subscription Year

Out-of-State

Volume 14,
Numbers 1-3

By completing this subscription form, you are agreeing to receive the REPORTER from the Indiana Resource Center for Autism and additional information on autism spectrum disorders and other disabilities from the Indiana Institute on Disability and Community at Indiana University, Bloomington. Individuals completing this form may also be invited to participate in various research projects conducted by the IRCA.
If you do not want to be contacted regarding research, please check this box.
The REPORTER is free for Indiana residents. If you wish to subscribe to the REPORTER, simply return the completed form to Pam Anderson, Indiana Institute on Disability and Community, 2853 East Tenth Street, Bloomington, IN 47408-2696, fax to (812) 855-9630, or call (812) 855-6508.

The REPORTER subscription fee for individuals and agencies outside of Indiana is $25 each year. For subscribers outside the United States, the fee is $45 and must be paid with a Visa, MasterCard, or Discover credit card. No international checks or money orders will be accepted. The subscription year runs from July through June. To subscribe, return the completed form and payment to Pam Anderson, Indiana Institute on Disability and Community, 2853 East Tenth Street, Bloomington, IN 47408-2696. Make checks and purchase orders payable to Indiana University.

PLEASE TYPE OR PRINT

Date: ________________ Name: __________________________________

Agency Position: __________________ Agency: ____________________

Street Address: _______________________________________________

City: _________________________State: _________ Zip: ___________

County: _________________________Country________________

Phone: (________) _______________Fax: (_______) ________________

E-mail Address: ____________________
If your address changes or you decide in the future that you no longer wish to have your name and address on our mailing list, please notify us accordingly.

Are you a parent of a person with autism spectrum disorder? ____Yes ____No

IF YES: ___ Son or ___ Daughter

Individual's Name:_________________________Birthdate _____________

IF NO: Are you related to a person with autism? ____Yes ____No

Are you a person with autism? ____Yes ____No

To submit form if you are out-of-state:
This form must be printed and sent with a payment of $25.00 to:
Pam Anderson
IRCA/IIDC
2853 East Tenth Street
Bloomington, IN 47408-2696
FAX: 812-855-9630