Application for Dreams Take Flight 2020 Question Title * 1. First name of your child Question Title * 2. Middle name of your child Question Title * 3. Last name of your child Question Title * 4. Date of Birth (MM/DD/YY) Children must be from the age of 6 to a maximum of 12 years old, born 2008 – May 2014 only. Date Date Question Title * 5. Has your child been diagnosed with ASD? Yes No Question Title * 6. Guardian / Parents Full Name Question Title * 7. E-mail Address Question Title * 8. Contact Number Question Title * 9. Home Address Address Address 2 City/Town State/Province ZIP/Postal Code Country Question Title * 10. Gender Male Female Question Title * 11. Nationality Canadian American Question Title * 12. Valid Canadian or American Passport Yes No Question Title * 13. Birth Certificate Canada United States Question Title * 14. Do you identify as a visible minority? Yes No Prefer not to say Question Title * 15. Level of Education? Elementary Junior High High School Question Title * 16. How does the participant typically communicate? Verbally, using spoken sentences Verbally, using spoken phrases or single words Non-verbally, using augmentative or alternative communication device to generate sentences (e.g. computer or sign language) Non-verbally, using augmentative or alternative communication device to generate phrases (e.g. computer or sign language) Minimal communication: may use vocalizations, gestures Question Title * 17. On an average weekly basis, how often is the participant involved in activities outside of school (e.g. martial arts, going to library, scouts, etc.) Does not engage in extracurricular activities One extracurricular activity Two extracurricular activities Three extracurricular activities More than three extracurricular activities Question Title * 18. How did you hear about this program? Question Title * 19. Is this your child's first flying experience? Yes No Question Title * 20. Is this the first time for the participant to visit Disney World? Yes No Question Title * 21. Which of the following best describes on average the participant’s previous social experiences: Extremely negative Mostly negative Somewhat negative Neutral Somewhat positive Mostly positive Question Title * 22. What is the most important reason for your child to attend this program? Question Title * 23. Please add any notes that may be helpful to our program organizers or any questions you may have. I.E. "My child has a difficult time with... / My child best communicates when..." Question Title * 24. Consent to share information & photo Yes No Question Title * 25. If you haven't already, do you want join our mailing list to keep up with all Jake's House events & activities? Yes, ofcourse No, thank you Done