Bermuda Autism Support and Education | BermudaTix part of the Incentis family

Online Membership renewal/application form
Registered Charity #590

Bermuda Autism Support and Education *

$ 25.00 Memberships BASE

BermudaTix fee *

$ 2.00 BermudaTix fee

Optional Donation

x $ 1.00

Total Amount

Email Address *

I am contributing on behalf of an organization.

Organization Details

Organization Name *

Start typing the name of an organization that you have saved previously to use it again. Otherwise click "Enter a new organization" above.

Email Address *

First name (org)

Last name (org)

Title

First Name *

Last Name *

Street Address (Home) *

City (Leave blank for Bermuda addresses)

Postal Code (Home)

Country (Home) *

State/Province/Parish (Home) *

Phone-Phone (Primary) *

PARENT PLEASE COMPLETE

Children (diagnosed and siblings)
Child One

Name

Birth Date

(clear)

Sex

Diagnosis

Child Two

Name

Birth Date

(clear)

Sex

Diagnosis

Child Three

Name

Birth Date

(clear)

Sex

Diagnosis

Child Four

Name

Birth Date

(clear)

Sex

Diagnosis

PROFESSIONALS PLEASE COMPLETE

Would you like your name and number posted on our professionals list?

Yes No(clear)
(This list would be available only to the professionals in our membership and the executive committee)

Would you like your name and number posted on our general membership list?

Yes No(clear)
(This list would be available to ALL members)

Credit Card Information

Card Type *

Card Number *

Security Code *

Usually the last 3-4 digits in the signature area on the back of the card.

Expiration Date *

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City

leave blank in Bermuda

Country *

State/Province

Postal Code *

Speech	Physical therapy	Education	Occupational therapy
Sensory integration	Diet	Behavioral therapy	Other