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Add Your Loved One with Autism

 
Please fill in the following form to submit information about your Autistic loved one to Racing Against Autism. You may tell as much or as little about you and your loved one as you feel comfortable with. This information helps us spread the word about Autism and who it affects.
 
We will create a puzzle piece with your childs name, age and city to showcase on the Racing Against Autism Pantera. In addition, if you submit a photo, we will display it on our Wall of Autism with name, age and location.
 
Items with an asterisk (*) are required and will be published on line and/or on our Racing Against Autism Pantera. Please read the information items by rolling your mouse over the info icon.
 
First Name * :: The first name of the person with Autism. By submitting this information you agree to it's publication on line and on a puzzle piece on the Racing Against Autism Pantera.
 
Last Name :: Not required, but will be published on line and on the puzzle piece for the Racing Against Autism Pantera if you submit it.
 
Age * :: We appreciate knowing the age of your Autistic Loved One to help show others how young this affects our children.
 
City :: Not required, but will be published on line if you submit it.
 
State :: Not required, but will be published on line if you submit it.
 
Diagnosis :: What type of Autism was your child diagnosed with? Where on the spectrum do they fall?
 
Age when diagnosed :: How old was your Loved One when diagnosed?
 
email address :: Not required but if you submit your email address we may update you on what's happening with Racing Against Autism. We will otherwise keep your email private.
 
Upload a photo of your Autistic loved one :: Please keep photos limited to less than 1Mb. We may edit your photo for size and composition. By submitting a photo you agree to having it published on our Wall of Autism.
 
Anything else :: Is there anything else you would like us to know?
 
 
 
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