Holiday Application Form 1. Contact DetailsName First Last Address Street No. Suburb State Post Code Phone (home) Phone (mobile) Email 2. Who will be attending this holiday?Number of AdultsNo. of AdultsNumber of ChildrenNo. of ChildrenAges of ChildrenAges of ChildrenNumber of Children with a diagnosis of Autism3. Details of Children with AutismChild No. 1Name First Last Birth Date DD slash MM slash YYYY Current Doctor/Psychologist's name First Last Current Doctor/Psychologist's phone no.Child no. 2Name First Last Birth Date DD slash MM slash YYYY Current Doctor/Psychologist's name First Last Curent Doctor/Psychologist's phone no.4. Where and When would you like your holiday?1st Choice Arrival date DD slash MM slash YYYY Departure date DD slash MM slash YYYY 2nd Choice Arrival date DD slash MM slash YYYY Departure date DD slash MM slash YYYY Note: The AFHA will pay accommodation costs up to $1,000 - the bond, if requested, will also be paid separately.I am applying for a short holiday stay through the AFHA. I understand this is a family holiday and must include my child/children with autism. I also understand that the AFHA will pay for the accommodation and bond of my requested short stay ONLY and I will be responsible for ALL other costs. I hereby authorise the Doctor/Psychologist named above to give information regarding my child/children with autism to the AFHA if requested.If requested by the accommodation providers I will provide my car registration no. and/or a copy of my drivers licence(Required) Yes I agree Signed by First Last NameThis field is for validation purposes and should be left unchanged.
