APPLY – The Empress Walk Women's Health Organization

1. Contact Information

Name

Phone No

Age

Gender

2. Household Income

3. Education

4. Cultural Background
Parents Cultural Background

Do you identify as an African, Caribbean, Black (ACB) individual?

Yes No

Does your child identify as an African, Caribbean, Black (ACB) individual?

Yes No

Do you live in Metropolitan Toronto?

Yes No

5. Immigration Status
Parents Immigration Status

6. Autism Information

Are you a parent of a child with an official diagnosis of Autism Spectrum Disorder?

Yes No

Child Age

7. Language Information

8. Autism-related Services

Are you on a waitlist for any Autism-related funding or services?

Yes No

10. Program Participation

11. Filming Consent

Do you agree to being filmed during the program for research and marketing purposes?

Yes No

Do you agree to having your child(ren) filmed during the program for research and marketing purposes?

Yes No

Are you interested and willing to take part in a separate documentary series about African, Caribbean, Black (ACB) families and children with Autism Spectrum Disorder in Canada?

Yes No

Would you allow your child to take part in a separate documentary series about African, Caribbean, Black (ACB) families and children with Autism Spectrum Disorder in Canada?

Yes No

12. Agreement

I agree that the above information provided is true and accurate to the best of my knowledge and ability. I understand that the above information will be kept confidential and will be used for eligibility, research, and related purposes in accordance with the policies and practices of The Empress Walk Initiative and its organization. I am fully aware of the eligibility requirements and understand that I may or may not be selected for the program. I also understand that The Empress Walk retains the right to share and release the above information that I provided to other parties, agents, and partners as part of any agreements and obligations related to The Empress Walk Initiative.

The Empress Walk Initiative Eligibility Questionnaire & Project Application