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First name*

Last name*

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Email*

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Address

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Main Language Spoken at Home

How did you hear about the ACN?

Please tell us about your family

Parent/Guardian

Child Name

Primary Diagnosis

Secondary Diagnosis

By requesting membership, ACN will use your information to manage your account and for other purposes described in our privacy policy.*

By requesting membership to ACN you are confirming: You have an autism diagnosis or are a parent/carer of someone formally diagnosed with autism. Alternatively, you are in the process of obtaining a formal diagnosis for yourself or a family member. By registering with the ACN you agree to comply with our Code of Conduct and to interact with all other persons involved with this organisation in a courteous and respectful manner at all times.*

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