AIA Gift Basket Give-Away!
Please complete the following questions for a chance to win one of many AIA gift baskets! Your child's gift will be customized by our staff to match your child's individual needs! We will ship free of charge.
Privacy Statement
The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for the use of the person(s) named below.

AIA will not sell, reproduce, disseminate, or use the following information for any purpose other than to create your child's gift basket.
Child's name *
Gender *
Age *
Describe your child's diagnosis, behavioral challenges, and any toy preferences they may have - your gift basket will be customized by our staff to match your child's individual needs!
Please select if applicable: *
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This form was created inside of Arizona Institute for Autism (AIA).