FANZ Programme (Two Days) Framework for Autism in New Zealand Registration Form

Autism New Zealand is thrilled to offer the Southland Region two special FANZ courses, thanks to funds raised by Fight for Kidz 2016. Please see the reverse side of this form for more information.

Personal Details *indicates a required field

First Name*       Surname*      Organisation(if applicable)      Full Address(including postcode)*      Landline(including area code)       Mobile Phone      

Email Address      

Ethnicity       Gender      

Programme DetailsDate & Location of Way to Play programme(click for drop down menu) Select

Programme Cost (per person) $10.00 Family/Whānau $20.00 Professional

Payment Details – Please select ONEGST number 64-234-382. When completed, this registration form is your tax invoice. Please keep a copy for your records.Cheque Please make cheques payable to ‘Autism New Zealand’

Visa

Mastercard

Card Number      

Name on Card      

Expiry       CCV Number

Direct Banking

Amount Paid $      Date PaidAccount details: Autism New Zealand, 03 0866 0356307 01Direct banking reference: FANZ, Area of Programme, Participant Name

Invoice

Please provide details of who to send the invoice to (i.e. accounts):

Name      

Physical Address      

Email Address      

How did you hear about this programme?AutismNZ Staff Website Facebook Childcare

Other (please specify)      

Autism New Zealand Membership (automatic)1

Autism New Zealand FANZ Registration Form: Last Updated 7/05/2023Author: Morgan Ryan, Education Coordinator R:\Education\Registration Form Master Copies

FANZ Programme (Two Days) Framework for Autism in New Zealand Registration FormBy signing up to this programme you agree to be added to the Autism New Zealand MembershipTick here to receive email updates and further information from Autism New ZealandOther Ways to Help Please indicate if you’d like us to contact you about the following

Information about volunteeringInformation on making a regular donationInformation on making a bequestDonatingI would like to make a $      donation to Autism New Zealand using the payment details on the previous pageImportant InformationContent: The regular FANZ is an introductory course on autism which can be applied to understanding people with autism of all ages, though does have examples mostly from children. With the funds from Fight for Kidz we have decided to offer a second FANZ course for Southland that has a more specific focus on understanding and inter-acting with adults with autism.Payment: Payment must be made prior to the programme to confirm your place. We have various payment options available (cheque, credit card, direct banking and invoice), please only select one. Invoices will be sent at any time after the registration form has been received, and need to be paid one week before the course, if not earlier. Credit card payments will be processed one – two weeks before the course. Receipts will not be sent unless requested.Programme Cancellation Policy: Cancellations must be sent in writing, (mailed or emailed), to Autism New Zealand. Cancellations received up to 30 days prior to the course date receive a full refund, less a 10% handling fee. Cancellations received less than 30 days and up to seven days prior to the course will receive a 50% refund. No refunds will be given for cancellations received within seven days of the course; however a substitute delegate may be nominated.

Times: The programme runs from 9.30am – 3.30pm (both days) unless otherwise advised.

Family/Whānau: Includes wider family members, caregivers and individuals with autism. Students (16+ years) are also welcome.

Registration: Confirmation of your registration will be on a first-booked and paid basis.

Confirmation: Participants will receive an email response acknowledging the receipt of their form at the time it is read. Forms not sent through email may not receive an acknowledgement. All participants will receive a confirmation/reminder email around two weeks prior to the programme starting. If no email address is provided we cannot confirm you will receive a reminder.Autism New Zealand reserves the right to change, postpone, or cancel our education programmes at our discretion. Registered participants will be notified by email as soon as possible.Maximum participants (can be changed at Autism New Zealand’s discretion): 25 Minimum participants (programme subject to postponement or cancellation if not reached): 10

When completed, please return with payment to Autism New Zealand, National Office

Email: training@autismnz.org.nz (preferred)Postal: PO Box 33481, Petone, Lower Hutt 5046 Fax: 04 803 3502, Ph: 04 803 3501Website: http://www.autismnz.org.nz

Please check the website for contact details of your local Autism New Zealand Branch

2Autism New Zealand FANZ Registration Form: Last Updated 7/05/2023Author: Morgan Ryan, Education Coordinator R:\Education\Registration Form Master Copies