New Mexico Autism Society Member Application for Educational Stipends

Name________________________________ Check One: ____ Parent
Address_______________________________ ____ Professional

City, State, Zip_________________________ ____ Person with autism

Phone_______________________________ ____ Other___________

Membership expiration date_____________ (Check newsletter label)

Educational or Training Program Information

Title____________________________________________________________
Location_________________________________________________________

Date(s)____________________ Registration cost _______________________

Please attach supporting documentation, for example, conference brochure, registration form, receipt, etc.

For information on requirements for stipends, please refer to NMAS Stipend Guidelines. Please call (505) 332-0306 for assistance. (This number is a voice mailbox.)

I agree to share what I have learned with:

NMAS Meeting _____

NMAS Newsletter____

Other (please specify)________________________________

Signature_______________________________________

Please return completed form to:

New Mexico Autism Society

PO Box 30955 Albuquerque, NM 87190

Financial assistance may also be available through:

Your local school district (contact the Director of Special Education),

Developmental Disabilities Planning Council (505) 827-7590

435 St. Michael’s Dr-Bldg. D, Santa Fe, NM 87501

Autism Society of America 1-800-3AUTISM