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IGNITE Program Interest Form

IGNITE Program Interest Form

Thanks for your interest in the IGNITE program, with locations in Davidson, Greensboro, and Raleigh. Please complete the following form so that we can learn more about you and your interest in our program.

Participant Info
Participant Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State
Zip Code*
County*
Email*
Phone*
Parent or Guardian
Participant Name
Prefix First Last
Relationship
Address
Street Address Address Line 2 City State
Zip Code
County
Email
Phone
Please share your ethnicity:*
- Asian
- Black/African American
- Caucasian/White
- Hispanic or Latino
- Native American or Other Indigenous
- Native Hawaiian or Pacific Islander
- Two or More Races
- Other/Unknown
- Prefer not to answer
Questions for Participant
Please select the IGNITE location you are interested in.*
- Davidson
- Greensboro
- Raleigh
Please select the program you are interested in applying to: IGNITE for young adults or Jumpstart, our summer program for rising high school seniors or SPARK in Greensboro*
- IGNITE
- Jumpstart
- SPARK
Please select the program you are interested in applying to: IGNITE for young adults or Jumpstart, our summer program for rising high school seniors*
- IGNITE
- Jumpstart
Do you have a primary diagnosis of Autism Spectrum Disorder (ASD) or Asperger's Syndrome?*
- Yes
- No
Are you, the participant, your own legal guardian?*
- Yes, I am my own legal guardian
- No, I have a court appointed guardian - Full Guardiaship
- No, I have a court appointed guardian - Partial Guardiaship
- I don't know
Have you graduated from high school with a diploma or GED?*
- Yes
- No
Are you receiving, or have you received services from the Autism Society of North Carolina?*
- Yes
- No
- I'm unsure
Please describe the service(s)
Do you receive Vocational Rehabilitation Services?*
- Yes
- No
Do you have access to transportation?*
- Yes
- No
Can you describe what you do in a typical weekday?*
What are your special interests or hobbies?*
Please share information about any work or volunteer experience(s)
Please share why you are interested in IGNITE*
Please attach your most recent Diagnostic Evaluation and guardianship paperwork, if applicable, and any other documents that you feel might help us support you.
Drop files here or

Max. file size: 300 MB.
Please share how you learned about IGNITE

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