Acct#MI-02-130 / Cecelia Hammond MI Unlocking Autism Re.
Unlocking Autism
National Autism Awareness Project
(Registration Form)
The Open Your Eyes project was displayed again this year at the Power of ONE! Rally in April, 2002 in
Washington, DC and most recently visited Indianapolis, IN for the National ASA Conference in July, 2002.
During the year, the boards will be available for education and awareness in the individual states. The
display, should we reach our goal, will be 15 football fields long. Please help spread the word by coping
and distributing this form.
( ) FIRST TIME PICTURE
( ) REPLACEMENT PICTURE
Parent's Name: ___________________________________________ (if person with autism is under 18)
Address: _____________________________________________________________________________
City: ____________________________ State: ____________________ (Required) Zip: _____________
Phone Number: ______ - ______ - _____________ Email Address: ___________________________
Person with Autism: ________________________________________ Age _______________________
I" I hereby authorize Unlocking Autism to use this picture for the purpose of the Open Your Eyes Project"
Parent/Guardian's Signature: _______________________________________ (Required)
CHECK ALL THAT APPLY BELOW
( ) I wish to be contacted about future projects.
( ) My child's picture may be used for promotional item dealing with this project.
( ) I would be happy to serve on a parent network line for newly diagnosed chilren.
( ) I believe my child had a vaccine reaction that resulted in his/her autism.
( ) I HAVE ENCLOSED AN UPDATED PICTURE TO REPLACE A PICTURE ALREADY SENT IN!
Additional Information about me or my child:
Please mail with ANY SIZE picture to:
MI UA REP. Cecelia Hammond at: Open Your Eyes Project, P. O. Box 1403, Taylor, MI 48180
Any question call: 734-287-8898
or Unlocking Autism, P. O. Box 237, Walker LA 70785
Office: 225-665-7270
A donation of only $ 5.00 will cover the cost of materials for ONE person's picture. Please make an on-line donation. You can contribute in a private and secure mode by visiting www.unlockingautism.org and going to the donations screen.
