Apply for Adult Autism Classes

Name *

First

Middle

Last

Preferred Name

Email *

Sex

Male
Female
Prefer To Not Answer

Address *

City *

Zip Code *

Phone Number *

Birthdate *

Are you a member of the Inland Regional Center?

(If "Yes" please answer the question below)

If yes, what is your UCI number?

(If you are not a member of the Inland Regional Center, just leave this blank)

Citizenship

US Citizen
Dual US Citizen
US Permanent Resident
Other Citizenship

If you are not a US citizen and live in the United States, how long have you been in the country?

Current School Name

Or past school name

Graduation Date

Or expected graduation date

Type of School

Public
Independent
Religious
Homeschool

School Address

City

Have you ever received a disciplinary violation at school that resulted in your suspension, removal, or expulsion?

Yes
No

No judgement. We just need to know.

If yes, please explain the circumstances and the appropriate date of the incident(s).

What would you like us to know about the way you learn?

Which accommodations have helped you in the past?

Select all that apply. Hold "Control" on your keyboard to select more than one

If your favored accommodation is not on the list, what helps you learn?

Do you have an official diagnosis of Autism? *

Yes
No

Have you ever had an Individual Education Plan? *

Yes
No

What are your strengths? *

What goals would you like to set for yourself?

Desired Career Path *

Do you already have work or volunteer experience?

Do you belong to any social organizations or groups?

What are you social skills goals?

What do you like to do in your free time?

Do you have your own phone?

Yes
No

Do you have your own email address?

Yes
No

Do you have a computer?

Yes
No

Do you live with parents/family members/guardians?

Yes
No

Do you pay your own bills?

Yes
No

Do you have your driver's license?

Yes
No

Do you drive your own car?

Yes
No

If no, do you have experience using public transportation?

Yes
No

Please list any current or previous health problems you have experienced.

(seizures, head injuries, diabetes, sleep disturbances)

Is there anything else you would like us to know about you?

Feel free to write anything here. We want to get to know you.