ANUABA Membership Form

ANUABA Membership Form
Select your membership type:

Individual MembershipAgency Membership
Date of Certification

MonthDayYear
Date
Name*

First NameLast Name
Certification*

RBTBCaBABCBABCBA-DStudentParentOther
Do you identify or have you been diagnosed as Neurodiverse?

YesNoI'd rather not answer
What state do you practice?
Donation

Yes, I would like to make a donation to ANUABANo, I do not want to make a donation to ANUABA
Agency Name
Agency Number of Providers

1-910-5051+
Agency Primary State of Practice
Agency Representative Certification

RBTBCaBABCBABCBA-DStudentParentOther
Our Commitments:
ANU-ABA members are committed to repudiating the following practices:*

Electric shockConversion therapySeclusionRestraintTreatment of non-harmful self-stimmingForced eye contactForced social interactionsWithholding special interests to use as reinforcersEscape extinction for non-harmful self-stimming
ANU-ABA members are committed to adhering to and encouraging the following practices:*

Appropriate transition period for clients and providersUsing assent/consent in treatmentOrganizing case-load size based on experience and staffing under BACB standardsAmplifying, attending to, and adhering to Autistic voicesHiring Autistic in corporate office and field-based positions whenever possible.Neurodiverse OBM and Employee evaluations that are suitable for Autistic individualsChange culture of ABA to make more affirming and supportive to Neurodivergent communities
By clicking this box, Agency Representative listed above indicates he / she has authority to make commitments on behalf of the above-named agency.

I have the authority to make commitments on behalf of the above-named agency.
This certificate verifies that the aforementioned individual or entity has committed to the

principles of the Autistic and Neurodiverse United Association of Behavior Analysis and has

been designated "Autistic Approved".
Signature*

Clear
Contact Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Communications (We do not sell member information to third parties)

I would like to be contacted by phone by one of the ANUABA Board MembersI would like to receive text messages about AUNABA programs, apps, and eventsNone of the above.
How did you hear about us?*

FacebookGoogleFriend or ColleagueOther
Notes/Messages
Select your Donation or Membership
prevnext( X )
Donation $0
$ Free   Quantity



Donation $5
$5.00 Quantity



Donation $10
$10.00 Quantity



Donation $25
$25.00 Quantity



Agencies 9 or less
$48.00 Quantity



Agencies of 10-50
$96.00 Quantity



Agencies of 51+
$148.00 Quantity



Total

$0.00

Should be Empty:

ANUABA Membership Form

Our Commitments:

Contact Information