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REGISTER YOUR CHILD WITH US [Page 2]

Continue here if you have other children to register, or further comments to make. Remember to provide details of name and email address so that we keep your records together.

ALL INFORMATION PROVIDED STRICTLY CONFIDENTIAL

All Information Strictly Confidential - Register Your Child

Full Name
Email address
Third Child's Full Name
DOB
Diagnosed/Undiagnosed
Age at and Nature of Diagnosis
School Attended
Fourth Child's Full Name
DOB
Diagnosed/Undiagnosed
Age at and Nature of Diagnosis
School Attended


FURTHER INFORMATION

Please use this section to give us any additional information you wish.

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REGISTER YOUR INTEREST

Please help us build our data-base into an accurate picture of the number of children in Tasmania who are on the autistic spectrum. Let others know about this register.

ATAC - Action for Tasmanian Autistic Children!

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