Life Skills Class Pre-enrollment Application Form Question Title * 1. Parent/Guardian name Question Title * 2. Parent/Guardian email Question Title * 3. Parent/Guardian home number Question Title * 4. Parent/Guardian cell number Question Title * 5. ASD participant full name Question Title * 6. ASD participant age Question Title * 7. ASD participant date of birth? Date Date Question Title * 8. Is participant prone to wandering? Yes No Please elaborate Question Title * 9. Can he/she communicate in 1-2 words sentences? Yes No Please elaborate Question Title * 10. Can participant completely state his/her needs? Yes No Please elaborate Question Title * 11. Is he/she independent in toileting and associated use of facilities? Yes No Please elaborate Question Title * 12. Is participant able to manage his/her negative emotions (ie. anger, sadness, etc.)? Yes No Please elaborate Question Title * 13. Can he/she follow simple 1-2 step directions? Yes No Please elaborate Question Title * 14. Is participant able to read basic instructions/steps (ie. recipe)? Yes No Please elaborate Question Title * 15. Is he/she able to perform basic math, such as adding, subtracting, and multiplying? Yes No Please elaborate Question Title * 16. What chores or home maintenance tasks does the participant complete at home? (Please select all that apply) Cooking Laundry Washing dishes Vacuuming Taking out the trash Other cleaning tasks Outside work (ie, mowing the lawn, raking leaves) Other (please share specifics) Question Title * 17. Referring to the previous question, which tasks do you believe your loved one has the potential for growth in, or what tasks do you want to see him/her become more independent in? (Please select all that apply) Cooking Laundry Washing dishes Vacuuming Taking out the trash Other cleaning tasks Outside work (ie, mowing the lawn, raking leaves) Please elaborate Question Title * 18. What are some skills you would like to see the participant develop, practice, or strengthen? (Please select all that apply) Stress management Anger management Hygiene and self-care Time management Social engagement and appropriateness Following directions or steps to an activity Other (please share specifics) Question Title * 19. What are the participants areas of interest at home or school? Question Title * 20. How does the participant learn best? (Please select all that apply) Step-by-step directions (written directions) Written directions with images Visual directions (being shown) Hands-on learning Verbal prompting/cues Other (please share specifics) Question Title * 21. Below, please share with us any and all additional information about the participant that would assist us in making this experience successful for them. Examples include but are not limited to: Triggers. Behavioral concerns. Sensory sensitivities. Means of de-escalation. Question Title * 22. Participants are required to have a formal ASD diagnosis on file with the Autism Support and Resource Center. If the participant does not have a diagnosis on file, please submit diagnosis paperwork to asggc@yahoo.com at the time of application submittal. Applications will not be considered until proper diagnosis is received. Done