Holiday Application Form

1. Contact Details

Name
Address

2. Who will be attending this holiday?

No. of Adults
No. of Children
Ages of Children

3. Details of Children with Autism

Child No. 1

Name
DD slash MM slash YYYY
Current Doctor/Psychologist's name

Child no. 2

Name
DD slash MM slash YYYY
Current Doctor/Psychologist's name

4. Where and When would you like your holiday?

DD slash MM slash YYYY
DD slash MM slash YYYY
DD slash MM slash YYYY
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)
Signed by
This field is for validation purposes and should be left unchanged.