Registration Form

Name	Age (if under 18)	Days attending (specify which day(s), or "All")	Fee category (A-F)

(Please list names of all family members who will attend, and ages of any children under 18)

Address_____________________________________

City/State/Zip________________________________

Phone (day)__________________________________

Phone (night)_________________________________

Email_______________________________________

ANI member household? ___ yes ____ no

(If one person in the household is an ANI member, then everyone in the household is eligible for the ANI member rate.)

If no, would you like to join? ________

Add $15 (for residents of North America) or $20 (for all other countries) to total.

OPTIONAL additional donation: ____________
Donation purpose: __ scholarships __ overall program enhancement __ wherever needed.

Total enclosed: _______________

Please remit payment, in U.S. dollars, to:

Autism Network International

P.O. Box 35448

Syracuse, NY 13235-5448

REGISTRATION MUST BE RECEIVED BY JUNE 15, 2003

If alternate materials format is needed, please indicate:

Braille __

Large Print __

Tape__

Disk___

Upon receipt of your registration, you will be sent a packet containing additional information including directions, a map to the camp, and menu information.

Registration Fees

Full registration: includes lodging Sunday night through Tuesday night, and meals from Sunday supper through Wednesday lunch.

	Member			Nonmember
Fee Category	Per day	or	3-day total	Per day	or	3-day total
A Adults with full-time jobs⁽¹⁾	85		235	92		255
B Children 12 and under⁽²⁾	50		135	55		155
C Teens 13-17⁽²⁾	70		195	75		215
D Adults without full-time jobs	70		195	75		215
E Adults living on disability or public assistance	45		130	50		150
F Full-time support people⁽³⁾	40		110	45		130

Note 1: We realize that not all full-time jobs are high paying. If you have a full-time job but can't afford this rate, add a note explaining this, and you may register at the rate for adults without full-time jobs.

Note 2: The rate for children and teens includes a supervised activity program for all children under 18. Staff:child ratio is approximately 1:6. If your child needs more support than this, please bring an aide for your child, or contact ANI about hiring extra staff for an additional fee.

Note 3: This rate is for people who are attending Autreat for the purpose of providing support for a disabled person who could not participate without a FULL-TIME helper. Examples are personal care attendants for adults and 1:1 aides for children.

Work Shift Rebate

Adults and teens paying for the full 3 days, meals, and overnights may earn a $20 work rebate. Pay the full cost when registering. The rebate will be given upon completion of a work shift during Autreat. Full-time support people are not eligible for work shift rebates; their rate is set $20 lower than anyone else's because we don't expect them to have time to do a work shift while also providing full-time support for another person.

Partial Registration Options

If attending days only, but making your own lodging arrangements off-site: Subtract $10 per person per day. Please indicate “Days only” on registration form.

If making your own meal arrangements and not eating meals provided by Autreat: Subtract $10 per person per day. Please indicate “No meals” on registration form.

A limited number of spaces is available for people to stay on-site in their own tents or campers. Contact ANI for availability and fee information.