Upstate ABA Screening Form

The purpose of the South Carolina Autism Society is to enable all individuals with autism spectrum disorders to reach their maximum potential.

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Upstate ABA Screening Form

Full Name *
Address *
City *
State *
Zip *
Phone *
Cell Phone *
Email *
Have you ever plead guilty, or no contest, or been convicted of a misdemeanor or felony? *	YesNo
Are you currently a student? *	YesNo
What is your degree or area of study?
If no, what is your highest level of education?
Have you had any experience working with children with autism? If so, briefly explain. *
Name of Reference
Relationship
Company
Address of Reference
Phone of Reference
I certify that my answers are true and complete to the best of my knowledge. If this screening application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Disclaimer and Electronic Signature *	Yes
Submit