Teen Social Club Application

Teen Social Club Application

Teen's Information
Teen's Name

First NameLast Name
Birth Date

MonthDayYear
Current Grade
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information
Name

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Does your child live with parent/guardian?

Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number

General Information about Your Child
What age was your child diagnosed with autism?
Does your child have any other diagnoses we should know about?
If yes, please explain briefly.
What school does your child attend?
What type of classroom is your child in?
What is the reason your child wants to join this group?
What is the reason that you want your child to join this group?
General Skills of Your Child

Interpersonal Skills
Introduces him/herself to someone new

YesNo
Introduces people to each other

YesNo
Makes eye contact (if able/willing)

YesNo
Uses manners

YesNo