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Full Name *

Email Address *

Contact Number

+60

New Password *

Confirm Password

Child's Name *

Gender *(Child)

Ethnicity * (Child)

Postcode of Residence *

Relationship with Child *

Is your child from a single or twin birth? *

Do you have another child diagnosed with autism? * Yes
No

Date of Birth * (Child)

Premature Born Pregnancy Duration (weeks)
Please fill in only if your child is born premature (before completing 37 weeks of pregnancy).

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