IGNITE Program Interest Form

Participant Info

Participant Name*

First Last

Date of Birth*

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
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