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Home
Why We Exist?
Mission/Vision Statement
FAQs
Staff / Board of Directors
Contact
Support Us

Shareity 1316

Home
Why We Exist?
Mission/Vision Statement
FAQs
Staff / Board of Directors
Contact
Support Us

×

Home
Why We Exist?
Mission/Vision Statement
FAQs
Staff / Board of Directors
Contact
Support Us

Home

Why We Exist?

Mission/Vision
Statement

FAQs

Contact

Support Us

Staff / Board of Directors

Compassionate Support Starts Here.

Connect with our Autism Family Support Team today.

(760) 646-1967
judesparentproject@gmail.com

"*" indicates required fields

Email

This field is for validation purposes and should be left unchanged.

1. Family Information

Parent / Guardian Name*

Phone Number*

Email*

Address

Street Address City State / Province / Region ZIP / Postal Code Country

2. Child Information

Child’s Name*

Age*

Autism Diagnosis

Yes

No

Date of Diagnosis (If Known)

MM slash DD slash YYYY

Support Needs (Briefly Describe)

3. Safety & Special Considerations

Does Your Child Have Wandering / Elopement Risk?

Yes

No

Sensory Sensitivities or Other Important Information

Anything Else We Should Know to Help Keep Your Child Safe and Supported?

4. Services Requested

Please Select All Services that Would Help Your Family Most.

House Cleaning

Laundry Service

Yardwork

Handyman Services

Mobile Car Wash

Date Night / Your Night

Free Haircuts

Dog Grooming

Bonus Service: Child Safety Alarm System (For Qualifying Families)

All services are provided at no cost to families, based on availability and eligibility.

5. Urgency Level

How Would You Rate Your Current Need for Support?

Low – We are managing okay right now.

Moderate – We could use support soon.

High – We are feeling overwhelmed and need help soon.

Urgent – We are in crisis and need immediate support.

Please Briefly Explain Your Current Situation

6. Additional Notes

Is There Anything Else You Would Like Us to Know About Your Family's Needs?

7. Consent & Agreement

Untitled

I Confirm that The Information Provided in This Application Is Accurate to The Best of My Knowledge.

I Understand that Services Are Based on Availability and Eligibility and That Completion of This Application Does Not Guarantee Services.

All information is kept confidential and used only to provide support to your family.

8. Signature

By signing below, I agree to the statements above.

Signature

Date

MM slash DD slash YYYY

Submit Application

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Name*

Email*

Phone*

Message

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(760) 646-1967
judesparentproject@gmail.com

Home
Why We Exist?
Mission/Vision Statement
FAQs
Staff / Board of Directors
Contact
Support Us

Home
Why We Exist?
Mission/Vision Statement
FAQs
Staff / Board of Directors
Contact
Support Us

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