Membership | Kildare Autism Network

Your First Name(Required)

Your Last Name(Required)

Your Email Address

Your Phone Number(Required)

Association with Child/Children(Required)

Mother or Father

Legal Guardian

Other

Your Address(Required)

Membership Plan(Required)

Family Membership

Parent & Guardian

Membership Type(Required)

1 Child Membership

2 Child Membership

3 Child Membership

4 Child Membership

Child’s Name(Required)

Child's Gender(Required)

Child's Date of Birth(Required)

Day

Month

Year

Does your child have an autism diagnosis?(Required)

Yes

Other

How does your Child communicate?(Required)

Verbal

Communication device

Lamh

Pecs

Other

Please specify how your Child communicates.

Are you currently under any disability services with the HSE/other?(Required)

Yes

Other

Does your child have a physical disability?(Required)

Does your child use aids for eating, drinking, walking, hearing?(Required)

What preschool/school/other education does your child attend?(Required)

Child’s Name(Required)

Child's Gender(Required)

Child's Date of Birth(Required)

Day

Month

Year

Does your child have an autism diagnosis?(Required)

Yes

Other

How does your Child communicate?(Required)

Verbal

Communication device

Lamh

Pecs

Other

Please specify how your Child communicates.

Are you currently under any disability services with the HSE/other?(Required)

Yes

Other

Does your child have a physical disability?(Required)

Does your child use aids for eating, drinking, walking, hearing?(Required)

What preschool/school/other education does your child attend?(Required)

Child’s Name(Required)

Child's Gender(Required)

Child's Date of Birth(Required)

Day

Month

Year

Does your child have an autism diagnosis?(Required)

Yes

Other

How does your Child communicate?(Required)

Verbal

Communication device

Lamh

Pecs

Other

Please specify how your Child communicates.

Are you currently under any disability services with the HSE/other?(Required)

Yes

Other

Does your child have a physical disability?(Required)

Does your child use aids for eating, drinking, walking, hearing?(Required)

What preschool/school/other education does your child attend?(Required)

Child’s Name(Required)

Child's Gender(Required)

Child's Date of Birth(Required)

Day

Month

Year

Does your child have an autism diagnosis?(Required)

Yes

Other

How does your Child communicate?(Required)

Verbal

Communication device

Lamh

Pecs

Other

Please specify how your Child communicates.

Are you currently under any disability services with the HSE/other?(Required)

Yes

Other

Does your child have a physical disability?(Required)

Does your child use aids for eating, drinking, walking, hearing?(Required)

What preschool/school/other education does your child attend?(Required)

I GIVE / DO NOT GIVE my permission for my child / children to take part in activities organised by Kildare Autism Network. I understand that these activities are being run by parents on a voluntary basis.(Required)

I give permission

I do not give permission

We will be taking photographs of our group activities for use on our K.A.N. Group (not the main page). Are you happy for your child to be included in these photographs? The picture taken by Kildare Autism Network are for the Closed Group Only.(Required)

I give permission

I do not give permission

Would you be interested in volunteering at some of our events?(Required)

Yes

Not at this time

What elements/activities/events would you like to participate in with Kildare Autism Network?(Required)

Membership(Required)

Price:

Credit Card

Card Details

Cardholder Name

Thank you for choosing to Support us!