Parents of Autistic Children POAC

Making a Difference... Now!                   Phone 732.888.1000

POAC Annual Free Family Picnic: Registration Form

POAC Annual Free Family Picnic: Registration Form
This event is open to all children with autism and their families. To register, please complete the form below. All fields are required unless otherwise noted. Information collected is and will be used for Grant writing purposes and data collection ONLY. POAC never sells or distributes any information gathered on this or any of its web sites.

First Name:
Last Name:
Address 1:
Address 2 (Optional):
City:
State/Province:
Zip/Postal Code:
County:
Phone:
Fax (Optional):
E-mail:
Are You a POAC Member:
Yes | No

Ethnicity:

How Many People Will Be Attending?