Westchester Advocates for Individuals with High Functioning Autism, Asperger Syndrome, and other PDDs

ParentLink Membership Application

 Please print this page and mail completed application to: ParentLink, c/o Kay Grisar, 62 West Orchard Rd., Chappaqua, NY 10514

        Name_________________________________________________________

        Address_______________________________________________________

        City ______________________________________State_____ZIP_________ 

        Phone_________________________________________________________

        E-mail_________________________________________________________

I am applying for membership as:

        ___Parent or Guardian   ___Grandparent  ___Other Relative  ___Friend 

___Teacher     ___Other Professional, please specify__________________ 

If you are a parent, please complete this section:

        Child's Name __________________________________DOB_____________

        Diagnosis____________________  Educational Label__________________

        Current School or Program________________________________________

I give permission for my name and phone number to be given to other parents who may have issues in common with me, such as children of the same age, or who attend the same school, or live nearby, or are having similar problems.  _____Yes    _____No

        Signature ________________________________________Date__________    

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Last modified: July 15, 2008