Membership Form - One Time Donation (2024)

Autism Pensacola Membership Form

Become a 2024 Autism Pensacola Member by completing the form below. All memberships are a one-time donation and will receive VIP notifications of upcoming events.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Your connection with autism

I am an individual on the spectrumI have a family member on the spectrumI am a professional serving individuals with autismI am a Community friend & supporter
Name & date of birth of individual(s) on the spectrum
Which programs and services would best serve your membership?

Autism Education & TrainingCampsRespite OpportunitiesSupport GroupsSafety InitiativesSocial Events/OpportunitiesOther
If you selected other, please tell us how we can best serve you:
Autism Pensacola does not sell or provide your information to anyone without your prior written consent.

Yes, please include me on your email list of upcoming events and other Autism Pensacola notifications.No, please do not include me in your email list.

My Products

Friend of APIMembership Perks: VIP Event Notifications

$25.00

Family MembershipMembership Perks: VIP Event Notifications, Kids for Camp Eligibility, (2) Respite/Event Tickets, OR (1) Adult Cooking Class Annually.

$50.00

Connector MembershipVIP Event Notifications, Kids for Camp Eligibility and Discounted Camp Application Fee, (4) Respite/Event Tickets OR (2) Adult Cooking Classes, 2023 Autism Pensacola Car Magnet.

$100.00

Business & Community LeaderMembership Perks: VIP Event Notifications, Kids for Camp Eligibility and Waived Application Fee, (5) Respite/Event Tickets OR (3) Adult Cooking Classes, Name/Business Recognition on the Membership Webpage, and (1) Autism Pensacola T-Shirt and Car Magnet.

$150.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Business & Community Leaders Only
Shirt sizes available in Adult Small to 3XL.
Should be Empty:

Autism Pensacola Membership Form