(IL) Urbana-Champaign Pilot Clinic

URBANA-CHAMPAIGN, IL
ACEing Autism Free Clinic
Saturday: May 31, 2025

11:00 am - 12:00 pm (ages 5-18+)

(IL) Urbana-Champaign*

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Is the participant new to ACEing Autism?*

How did you learn about ACEing Autism?*

Please elaborate on how you heard about ACEing Autism*

Has the participant taken part in ACEing Autism this calendar year?*

PARTICIPANT BASICS

Name*

Preferred First Name

Pronouns

Date of Birth*

Gender*

Dominant Hand*

Address*

Please provide a current headshot of the participant. This will only be used to identify them upon arrival to clinic and on the courts.

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It can be helpful for participants to wear their ACEing Autism shirt to clinics, but it is not required.

T-Shirt Size*

FAMILY INFORMATION
Parent / Guardian 1

Parent / Guardian Name*

Email*

Phone Number*

Yes, it's okay to send me text messages including confirmations, changes, updates, and/or promotions. Message frequency varies. Message and data rates may apply. View our terms of service & privacy policy.

Parent / Guardian 2

Parent / Guardian Name

Phone Number

Demographics

What is the participant's ethnicity / race? (Check all that apply)*

Black or African American
Caucasian or White
Hispanic or Latino
Native American
Native Hawaiian or other Pacific Islander
Asian
Other
Prefer not to answer

What is your estimated annual household income before taxes?*

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