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Membership Form
FAMILY INFORMATION
Your Category:
Parent/Legal Guardian
Caregiver
Siblings
Title:
Mr.
Mrs.
Ms.
Miss.
Other
Full Name:
*
Preferred Phone No
*
Email Address
*
Relationship to person to be registered:
Address:
Preferred Language(If not English):
Interpreter Required:
Yes
No
CHILD INFORMATION
Child Full Name
*
Diagnosis of ASD?
*
Yes
No
What service/support are you looking for?
Gender:
*
Male
Female
Other
Date of Birth:
Live with:
Parents
Mother
Father
Other(Please Specify):
Address:
Preferred Language(If not English):
Interpreter Required:
Yes
No
Residency Status:
Zanzibar
Tanzania Mainland
Other
Agree
*
Yes, I agree with the
privacy policy
and
terms and conditions
.
Submit
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