Family Membership Form Details of Parent(s) / Carer(s):Parent/Carer First Last Are you autistic? Yes No N/A Add Secondary Parent/Carer Add Secondary Parent/Carer Parent/Carer #2 First Last Are you autistic? Yes No N/A Email Phone Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Does anyone in your family identify as the following? (Optional): Aboriginal or Torres Strait Islander Culturally and Linguistically Diverse (CaLD) LGBTQIA+ Number of kids12345 Kid #1 DetailsName First Last Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Diagnosed with autism or other disability? Yes No Seeking Select from the list that applies Autism Intellectual Disability ADHD Cerebral Palsy Down Syndrome Psychosocial Disability (OCD, Bipolar Disorder, Schizophrenia, BPD etc.) Sensory Processing Disorder Epilepsy Ehler’s Danlos Syndrome / Hypermobility Spectrum Disorder Deaf / Hearing Loss Blind / Vision Impaired Neurological Disability (MS, MND etc.) Physical Disability Other Other: please specify Kid #2 DetailsName First Last Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Diagnosed with autism or other disability? Yes No Seeking Select from the list that applies Autism Intellectual Disability ADHD Cerebral Palsy Down Syndrome Psychosocial Disability (OCD, Bipolar Disorder, Schizophrenia, BPD etc.) Sensory Processing Disorder Epilepsy Ehler’s Danlos Syndrome / Hypermobility Spectrum Disorder Deaf / Hearing Loss Blind / Vision Impaired Neurological Disability (MS, MND etc.) Physical Disability Other Other: please specify Kid #3 DetailsName First Last Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Diagnosed with autism or other disability? Yes No Seeking Select from the list that applies Autism Intellectual Disability ADHD Cerebral Palsy Down Syndrome Psychosocial Disability (OCD, Bipolar Disorder, Schizophrenia, BPD etc.) Sensory Processing Disorder Epilepsy Ehler’s Danlos Syndrome / Hypermobility Spectrum Disorder Deaf / Hearing Loss Blind / Vision Impaired Neurological Disability (MS, MND etc.) Physical Disability Other Other: please specify Kid #4 DetailsName First Last Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Diagnosed with autism or other disability? Yes No Seeking Select from the list that applies Autism Intellectual Disability ADHD Cerebral Palsy Down Syndrome Psychosocial Disability (OCD, Bipolar Disorder, Schizophrenia, BPD etc.) Sensory Processing Disorder Epilepsy Ehler’s Danlos Syndrome / Hypermobility Spectrum Disorder Deaf / Hearing Loss Blind / Vision Impaired Neurological Disability (MS, MND etc.) Physical Disability Other Other: please specify Kid #5 DetailsName First Last Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Diagnosed with autism or other disability? Yes No Seeking Select from the list that applies Autism Intellectual Disability ADHD Cerebral Palsy Down Syndrome Psychosocial Disability (OCD, Bipolar Disorder, Schizophrenia, BPD etc.) Sensory Processing Disorder Epilepsy Ehler’s Danlos Syndrome / Hypermobility Spectrum Disorder Deaf / Hearing Loss Blind / Vision Impaired Neurological Disability (MS, MND etc.) Physical Disability Other Other: please specify Other information you would like us to know (optional):Would you like to hear from us?Consent I would like to receive the SWAN NewsletterI am able to volunteer with SWAN (please contact me): Yes No Would you like us to contact you to answer any questions or concerns that you currently have? Yes No EmailThis field is for validation purposes and should be left unchanged. Δ
