Recovering Autistic Children
Edited by Stephen M. Edelson, Ph.D. and Bernard Rimland, Ph.D.

Book Request Form for Military Families

Limit of ONE free book per Active Duty or Retired family.

Please print out this form and fax it to 619-563-6840 or mail to Autism Research Institute, 4182 Adams Avenue, San Diego, CA 92116. Include a copy of the front of your ID card.

Name
Address
City
State
Zip
Email
Telephone
Sponsor's Name
Sponsor's SSN
Service Branch

Please circle one     Active Duty     Retired

How did you learn about ARI's book offer?

Do you have a child in your family with an Autism Spectrum Disorder?

If yes, will you please fill out this short survey to help us identify how many children in the military have autism? If more than one child has been diagnosed, please answer for each child.

Child's Age: ________   Child's Sex: _____________

Diagnosis(circle one):   Autism   PDD   Asperger's

Age at diagnosis: _______________     Diagnosed by:   MTF   or   Civilian facility

Enrolled in EFMP?     yes   no       Enrolled in ECHO?   yes   no   N/A

Is your child receiving ABA now? __________    How many hours per week? _________

Is your child seeing a Defeat Autism Now! doctor?___________________________________________