Join Chalu
ASNCOC (Autism Society of
NC, Orange and Chatham Counties)
Application for Membership
Name __________________________________________________________________
Address ________________________________________________________________
Phone ______________________________Email_______________________________
Only include your email if you would like to receive our newsletter the
Rainman and any of our other updates.
Children’s names and ages __________________________________________________
______ $5.00 per person or
______ please waive dues/membership scholarship
______ + additional tax deductible donation
______ + $5.00 to sponsor a teacher ____________________________(name of
teacher)
__________________________________________________________(school name)
______ TOTAL
Permission for photos (for the period of Sept 2004-Sept 2005)
______ I give permission for my child’s or my likeness to be photographed and
placed in the Rainman.
______ I do not give my permission for my child or my likeness to be
photographed and placed in the Rainman.
Signature__________________________________________date_______________
In order to insure privacy, a unique link to the Rainman will be emailed to
every member for each edition. Only first names of the children will be given
and no addresses or phone numbers will be published unless permission is
granted. Adults may choose to have only their first name published as well and a
permission request will be signed and kept on file before any photo is placed in
the Rainman.
Please return this form with your check made out to CHALU to: Lori Slack,
Treasurer, 800 Emory Drive, Chapel Hill, NC 27517
On the back of this sheet please list suggestions for our future CHALU
meetings (e.g. Ideas for guest speakers, topics, events, etc)