REIMAGINING BLACK EXCELLENCE: Pathways for Success for Black Neurodiverse Youth and Families

Participant Eligibility Form

This intake form helps Ase Community Foundation understand who is joining the Reimagining Black Excellence program and supports our impact reporting to the Ontario Trillium Foundation (OTF), our funder.

All information is kept strictly confidential and will only be used for program delivery and aggregate reporting. No personally identifying information will be shared publicly.

Completing this form should take approximately 10–15 minutes.

Fields marked with * are required.

Note for Participants Under 18

If the participant is under 18 years of age, a parent or legal guardian must complete this form on their behalf and provide consent. Participants aged 13–17 are encouraged to complete Sections 2–6 themselves, with parent/guardian review.

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* 1. Who is completing this form?

I am the participant (age 18 or older)

I am a parent or legal guardian completing this on behalf of a participant under 18

I am a caregiver completing this on behalf of a participant under 18

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* 2. Your full name

First Name

Last Name

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* 3. What is your relationship to the participant?

Parent

Legal Guardian

Grandparent

I am 18 years or older—I am registering for myself

Other caregiver (please specify below)

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* 4. Email Address

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* 5. Do you or your child / youth self-identify as Black? ( African Canadian, Black, Afro-Caribbean, Afro-Latino, Afro-Indigenous, African American, or mixed-race of African descent)

Yes

Prefer not to answer

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* 6. Do you self-identify as a Black parent, caregiver, and/or guardian of a Black youth with disabilities?

In Canada, a disability is defined under the Accessible Canada Act as any physical, mental, intellectual, cognitive, learning, communication, or sensory impairment—or functional limitation—that, in interaction with a barrier, hinders a person's complete and equal participation in society. It includes permanent, temporary, or episodic conditions, whether evident or not.)

Yes

Prefer not to answer

Not Applicable—I am 18 years or older

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* 7. Do you (participant 18+) or your child (age 13-17) identify as neurodiverse/neurodivergent? (Diagnosed, Undiagnosed, or Self Diagnosed)

Neurodivergence is an umbrella term that refers to the natural variation in how people think, learn, process information, and experience the world. It includes differences such as ADHD, autism, learning disabilities, and mental health conditions. These are not deficits, but differences that reflect the diversity of human brains.

Yes

Not sure

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* 8. Do you and your child / youth live in the Durham Region of Ontario, Canada?

Please note that you and/or your child must reside in Durham, ON in order to be eligible to attend the program.

Pickering

Ajax

Whitby

Oshawa

Clarington

Bowmanville

Scucog

Brock

Uxbridge

No, we are NOT in the Durham Region

Other (please specify)

REIMAGINING BLACK EXCELLENCE: Pathways for Success for Black Neurodiverse Youth and Families

Participant Eligibility Form

Question Title

* 1. Who is completing this form?

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* 2. Your full name

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* 3. What is your relationship to the participant?

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* 4. Email Address

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* 5. Do you or your child / youth self-identify as Black? ( African Canadian, Black, Afro-Caribbean, Afro-Latino, Afro-Indigenous, African American, or mixed-race of African descent)

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* 8. Do you and your child / youth live in the Durham Region of Ontario, Canada?Please note that you and/or your child must reside in Durham, ON in order to be eligible to attend the program.

* 8. Do you and your child / youth live in the Durham Region of Ontario, Canada?

Please note that you and/or your child must reside in Durham, ON in order to be eligible to attend the program.