FLASH Membership Form
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Name Of Parent or Organisation
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Full Postal Address
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Postcode
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Email Address
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Confirm Email Address
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Telephone Number
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Mobile Number
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Name of Family Member with an Autistic Spectrum Disorder
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Date of Birth (DD-MM-YYYY)
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Nature of Condition
Autistic Spectrum Disorder
Aspergers Syndrome
Communication Difficulty
Other
Names of Other Children
Date of Birth (DD-MM-YYYY)
Where Did You Hear About FLASH
Are you willing to allow information to be held on a database for administration purposes only and not passed on to a third party?
Yes
Are you willing for photographs of your family to be used on the FLASH website?
Yes
Are you willing for photographs of your family to be used in FLASH publicity material?
Yes
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Indicates Response Required
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