Alex Autism Alliance – Participant Application Form

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Thank you for your interest in the Alex Autism Alliance. This form is an application to be considered for participation in our program. Please complete all sections honestly and thoroughly. Your responses will help us determine if the program is the right fit based on individual needs, strengths, and available support. All applications are reviewed by our team and subject to approval.

Please note: The Alex Autism Alliance is a free program offered at no cost to participating families. Our goal is to support individuals and families without financial burden.

Full Name - Participant *

DOB: *

YYYY

Email Address *

Confirm Email Address *

Phone Number *

Home Address *

Emergency Contact Name /Phone Number/ relashionship *

Who is completing this form?
*

The individual

A parent

A guardian

A caregiver

Relative

Other:

Full name of the person Completing this form and Phone Number *

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