Date and Location of FANZ Programme / Please select from the drop-down menu. /
Organisation Details (if applicable)
Name / Click here to enter text. /
Address / Click here to enter text. /
Phone(s) / Click here to enter text. / Email / Click here to enter text. /
Names for certificates will be taken from here, so please ensure spelling is correct.
Registrations or changes to participants within two weeks of programme start will not receive a certificate.
Primary Participant/Contact
Name / Click here to enter text. / Family/Whanau ($50) / ☐ / Professional ($175) / ☐
Phone(s) / Click here to enter text. / Email / Click here to enter text. /
Ethnicity / Click here to enter text. / Gender / Click here to enter text. / Branch / Please select. /
Additional Participants(please only register multiple participants from the same organisation, family group, and/or will be paid for together)
Name / Click here to enter text. / Family/Whanau ($50) / ☐ / Professional ($175) / ☐
Ethnicity / Click here to enter text. / Gender / Click here to enter text. / Branch / Please select. /
Name / Click here to enter text. / Family/Whanau ($50) / ☐ / Professional ($175) / ☐
Ethnicity / Click here to enter text. / Gender / Click here to enter text. / Branch / Please select. /
Name / Click here to enter text. / Family/Whanau ($50) / ☐ / Professional ($175) / ☐
Ethnicity / Click here to enter text. / Gender / Click here to enter text. / Branch / Please select. /
Payment (when completed, this registration form is your tax invoice, GST number 64-234-382)
Please select ONE payment method / Total Due / Click here to enter text. /
Cheque / ☐ / Please make cheques payable to Autism New Zealand
Visa
Mastercard / ☐
☐ / Card Number / Click here to enter text. /
Name on Card / Click here to enter text. /
Expiry / Click here to enter text. / CCV / Click here to enter text. /
Direct Banking / ☐ / Please deposit payment to Autism New Zealand, 03 0866 0356307 01
References: FANZ, Location of Programme, Surname
Date deposited / Click here to enter text. /
Invoice / ☐ / Organisation/Name / Click here to enter text. /
Physical Address / Click here to enter text. /
Email / Click here to enter text. /
How did you hear about the FANZ programme?
AutismNZ Staff ☐ / AutismNZ Website ☐ / Facebook ☐
Childcare/School ☐ / Healthcare/ASD Coordinator ☐ / Word of Mouth ☐
Other (please specify) / Click here to enter text. /
AutismNZ Membership (automatic, by signing up to this programme you agree to be added to the AutismNZ Membership)
Tick here to opt-in to email updates and further information from AutismNZ / ☐
Donating
Tick here if you would like to make a $Click here to enter text.donation to AutismNZ using the payment details given / ☐
Other Ways to Help
Tick here if you would like information about volunteering / ☐
Tick here if you would like information on making a regular donation / ☐
Tick here if you would like information on making a bequest / ☐
Important Information
Family/Whanau / This includes parents, primary caregivers, wider family/whanau members, and individuals with autism. Students (16+ years) are also welcome.You or the person/people you are supporting do not need an official diagnosis of autism.
Professionals / This includes all non-family/whanau participants including but not limited to;Teachers, RTLBs, Support Workers, Speech and Language Therapists, or others who may work with those with autism. You do not need to be currently working with a person with autism, or the person/people you are supporting do not need an official diagnosis of autism
Programme Times / This programme is a two day course, running from 9:30am – 3:30pm both days unless otherwise advertised. Some programmes may run from 10am – 4pm due to travel requirements. If a programme time is changed, registered participants will be notified by email as soon as possible.
Registration Confirmation / Registrations will be accepted on a first come – first served basis. Emailed forms (preferred) will receive an email response acknowledging the receipt of their form at the time the email is read (this will be sent to the email address that has sent through the form). Posted or faxed forms may not receive a confirmation of registration at the time they’re received.
All registered participants will receive an email reminder approximately two weeks prior to programme start (this will be sent to the email address provided on the form). If no email address is provided we cannot confirm you will receive a reminder.
If wanting to register more than four participants please send multiple forms, with up to four participants on each one. Only the primary contact will receive an email reminder and accepts responsibility for distributing programme information to all additional participants. If multiple participants would like to receive programme emails please send through separate forms with individuals as the primary contact.
If the programme is full at the time your form is received you will be put on a waitlist and notified as soon as possible if a space becomes available.
Minimum
Participants / Programme subject to postponement or cancellation if a minimum of 10 registered participants is not reached two weeks prior to programme start. Minimum numbers can be changed at AutismNZ’s discretion. Registered participants will be notified by the email provided on their form if the programme is cancelled.
Maximum Participants / Programme has a maximum participant number of 25. This can be changed at AutismNZ’s discretion. Registrations after 25 will be added to a waitlist. If a space becomes available waitlisted participants will be notified by email as soon as possible.
Payment / Payment is expected prior to programme start. We understand that waitlisted or late registrations may take a few days to process payment, and we accept that this may delay payment until after programme start. By filling in this form you agree to pay the stated amount as soon as possible. Please only select one payment method.
Invoices will be sent any time once minimum numbers have been met, between the registration form being received up to programme start (waitlisted or late registrations may have a delay). When possible it is expected that invoices be paid at least one week prior to programme start.
Credit card payments will be processed any time once minimum numbers have been met, between the registration form being received up to programme start (waitlisted or late registrations may have a delay).
Direct credit payments must be made prior to programme start.
Receipts will not be sent unless requested.
Refund Policy / If withdrawing from the programme this must be received in writing (mailed or emailed) to AutismNZ. Withdrawals received up to 30 days prior to the course date may receive a full refund minus a 10% administration fee. Cancellations received less than 30 and up to 7 days prior to the course may only receive a 50% refund. No refunds will be given for withdrawals received within seven days of the programme start, however you may offer your place to another participant or transfer your registration to a later programme.
Registered participants of programmes cancelled at AutismNZ’s discretion may receive a full refund. To redeem this refund please contact AutismNZ with your bank account details.
When completed please return this form to AutismNZ National Office
Email / (preferred) / Please direct any queries to , or check our website for contact details of your local branch
Post / PO Box 33481, Petone, Lower Hutt 5046
Autism New Zealand, FANZ Registration Form,