Thank you for taking the time to complete the Eligibility Questionnaire & Project Application. Completion will take approximately 3-5 minutes. The selection process for The Empress Walk Initiative is based on specific criteria. We will select a limited number of qualifying participants for the project. The Empress Walk will retain all application results for future use and research purposes. All information is kept confidential in accordance with our policies.
MaleFemaleNon-binaryPrefer not to say
Household with 1 person = $28,863 or less in incomeHousehold with 2 persons = $40,818 or less in incomeHousehold with 3 persons = $49,912 or less in incomeHousehold with 4 persons = $57,726 or less in incomeHousehold with 5 persons = $64,540 or less in incomeHousehold with 6 persons = $70,700 or less in incomeHousehold with 7 persons = $76,364 or less in incomeHousehold with 8 persons = $81,637 or less in incomeHousehold with 9 persons = $86,589 or less in incomeHousehold with 10 persons = $91,273 or less in income
No certificate, diploma or degreeHigh school diplomaPost-secondary certificateApprenticeship or trades certificateCollege diplomaUniversity degreeBachelor's degreeMaster's degreeDoctorate
Parents Cultural Background
Black CanadianBlack AmericanAfro-CaribbeanLatin-CaribbeanIndo-CaribbeanCaribbean - OtherSouth American - AfroSouth American - OtherAfricanMixed RaceOther
Child Cultural Background
Do you identify as an African, Caribbean, Black (ACB) individual?
YesNo
Does your child identify as an African, Caribbean, Black (ACB) individual?
Do you live in Metropolitan Toronto?
Parents Immigration Status
Canadian citizenPermanent residentNewcomer (Immigrant or Refugee in Canada for less than 5 years)Refugee
Child Immigration Status
Are you a parent of a child with an official diagnosis of Autism Spectrum Disorder?
0-5 years old6-10 years old11-15 years old16-17 years old18-24 years old25-29 years old30 plus years old
Does your child have siblings?
Do you speak more than one language?
EnglishFrenchSpanishPortugueseArabicSwahiliYorubaSomaliOther
Are you receiving any Autism-related services for your child?
Autism AssessmentsFamily ServicesSpeech & Language TherapyOccupational Therapy (OT)Assistive EquipmentEarly Years ProgramApplied Behavioural Analysis (ABA)Mental health servicesRespite services or specialized childcareEducational assistance or in school supportSocial worker or CaseworkerDisability Employment Agency or ProgramAutism Social GroupsPost-Secondary Accommodation or Accessibility ServicesOntario Autism Program (OAP)FPTChild Disability BenefitDisability Tax CreditOntario Disability Support Program (ODSP)Other
Are you on a waitlist for any Autism-related funding or services?
Less than 6 months6 months to 23 months2 years but less than 3 years3 years but less than 4 years4 years or more
No accommodation requiredYes, wheelchair accessibilityYes, sign language interpretationYes, transcription servicesYes, assistive listening devicesYes, amplification equipmentAccommodation and accessibility for visual impairment.Yes, Other
Are you willing to invest approximately 5 to 7 hours per week to participate in the program and complete all required activities?
Want to connect with an ACB cultural community of like-minded people who support neurodiversity and can relate to my experienceWant to network with ACB professionals and participate in programs and services without bias, inequality, racial or systemic discrimination against ACB individualsWant access to Autism services that are culturally sensitive and community orientedWant access to Autism services that are free or affordableWant to access Autism services in my local neighborhood or is easily accessible within the City of TorontoWant resources to manage my physical and mental healthWant resources to manage my child's physical and mental healthWant to learn more about Autism and neurodiversityOther
Improve my child's abilities, skills and development (language, mobility, cognition, self-regulation, etc.)Access resources and information about Autism Spectrum DisorderBe part of a community network and find supportManage my behavior and stressLearn the tools and techniques to manage and improve my mental and physical healthLearn the tools and techniques to manage and improve the mental and physical health of my childDevelop self-advocacy skillsGain system navigation knowledgeOther
Do you agree to being filmed during the program for research and marketing purposes?
Do you agree to having your child(ren) filmed during the program for research and marketing purposes?
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?
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?
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.
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