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Autism Ontario Durham Region - Young Adult Social Group Intake Form
Email address *
First Name *
Your answer
Last Name *
Your answer
Email Address *
Your answer
Address Line 1 *
Your answer
Address Line 2
Your answer
City *
Your answer
Province *
Postal Code *
Your answer
Home Phone No. *
Your answer
Cell Phone No. *
Your answer
Age *
Your answer
Emergency Contact Name *
Please provide first and last name. Must be an individual over the age of 18.
Your answer
Emergency Contact Phone No. *
Must be a cell phone number.
Your answer
Emergency Contact Email Address *
Your answer
Emergency Contact Address *
Your answer
Official Diagnoses *
Your answer
What are your goals for participating in this group? *
Your answer
What are your hobbies or interests?
Your answer
How independently can you function in social settings? *
If you answer "Requires some support", please specify in Other section, e.g. handling money, ordering, meeting new people, social interactions, etc.
Required
Do you require support with any of the following: *
Please choose all that apply.
Do you have any sensory challenges that may affect you at our events? *
Please choose all that apply.
Are you comfortable with using public transit with a group? *
Are there any other challenges that may affect you while participating in this group? *
Your answer
Please indicate any food allergies you may have. *
Your answer
Thank you for telling us about yourself. Please note that completing this form does not guarantee a spot in the group. You will be contacted by a group facilitator via telephone or email to obtain more details if necessary and confirm your eligibility for this group. Once your spot is confirmed you may register for group events.
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