XL.ENT Program Application & Questionnaire
The primary purpose of XL.ENT soccer is to provide a safe, fun learning environment for high-functioning individuals with ASD. In a supportive setting, players can learn how to play the game and learn life skills that can be generalized beyond the soccer field.

In order to participate, please fill out the application and questionnaire on behalf of your child. Our Raleigh pilot program is currently offered to high-functioning ASD kids. As our program grows, we hope to open up our program to children all along the spectrum. We will contact you via email if your child has been accepted into the program.
Email address *
Parent First Name *
Your answer
Parent Last Name *
Your answer
Child's First Name *
Your answer
Child's Last Name *
Your answer
Child's Date of Birth (MM/DD/YY) *
MM
/
DD
/
YYYY
Parent Phone Number *
Your answer
Parent Alternative Phone Number *
Your answer
Home Address *
Your answer
QUESTIONAIRE
Help us get to know your amazing child! Please answer the following questions.
Does your child have a diagnosis such as Autism Spectrum, ADHD, Sensory Processing Disorder? If so, please list. *
Your answer
Has your child played soccer or any other sport before? Please provide details. *
Your answer
What are your child's strengths? Challenges?
Your answer
Is your child able to listen, learn and follow multi-step instructions and apply them? *
Is your child able to wait his/her turn?
Is your child able to comprehend simplified game rules?
Is your child able to run the field for majority of the hour and stay within the momentum of the game? (We realize not everyone starts out with this full ability.) *
Is your child able to change directions while running? *
Is your child able to understand left/right direction along with forward/backward? *
Is your child able to get through practice/game with limited redirection. *
Does your child respond positively to coaching, as well as instructions and guidance from teammates? *
Is your child able to use the restroom without assistance? *
Is your child able to functionally, verbally communicate? *
Does your child exhibit aggressive verbal, physical or self-injurious behavior? *
Our Fall 2019 XL.ENT Soccer Crew!
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy