Birthday Club 2026
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Email *
First and last name of individual receiving the card *
Birthday Month *
Age group of individual receiving the card? *
Street address of individual receiving the card *
City  *
Zip Code *
Does the Birthday Club member have a dairy and/or gluten allergy? *
What is your relationship to Birthday Club member *
I attest that the Birthday Club member lives in one of the counties that Autism Society Central Ohio serves *
I attest that the Birthday Club member has a diagnosis of Autism and that the information above is correct.
 *
I understand that this form will need to be filled out each year to ensure address information is correct.
 *
A copy of your responses will be emailed to the address you provided.
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