Application For Activity Funding

We want our friends, who are diagnosed with an autism spectrum disorder (ASD) to be out in our North San Diego County Community, having fun in social activities!

Please complete the form below

Name of Participant

First Name

Last Name

Relationship to Participant

First Name

Last Name

Email Address

Phone

(###)

###

####

Home Address

Must live in North San Diego County, CA

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What social activity would the participant like to try, for 4 weeks?

(Choose one)

Art

Dance

Drama

Martial Arts

Music

Skateboard

Surf

Swim

Other (List below in comments section)

Comments