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NATIONAL AUTISM AWARENESS PROJECT REGISTRATION FORM......

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Unlocking Autism National Autism Awareness Project(Registration Form)

The goal of the Open Your Eyes project is to collect 58,000 pictures of people with autism spectrum disorders across the United States to be displayed again at the Hear-Their-Silence Rally, sponsored by Autism Resouce Konnection, in April, 2001 in Washington, D.C. The display, should we reach our goal, will be 15 football fields long. Please help spread the word by copying and distributing this form. INSTRUCTIONS: Press the PRINT button on your browser, complete and mail to the address at the bottom of this form. Please make your monetary donations by clicking the link below.

Parent's Name:__________________________________________(If person with autism is under 18)

Address:____________________________________________

City:___________________ State:________(Required) Zip:______________

Phone Number:_____-______-_______Email Address:___________________

Person with Autism:__________________ _______ Age:_______

"I hereby authorize Unlocking Autism to use this picture for the purpose of the Open Your Eyes Project."

Parent/Guardian's Signature:______________________________________(Required)

( ) I wish to be contacted about future projects.

( ) My child's picture may be used for promotional items dealing with this project.

( ) I would be happy to serve on a parent network line for newly diagnosed children.

( ) I believe my child had a vaccine reaction that resulted in his/her autism.

Additional Information about me or my child:

Please mail with ANY SIZE picture to:Unlocking AutismP.O. Box 1086Baton Rouge, LA 70821-1086Office: 225-926-3252

A donation of only $5.00 will cover the cost of materials for one person's picture. Please make an on-line donation. You can contribute in a private and secure mode by clicking here.

The DEADLINE for the 2001 Washington Display is March 10, 2001.

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