Golden Ticket Certificate Questionaire

. How would your son/daughter react to quick bursts of sound at 100 dB.
(Sound level commensurate to a muffler backfire or high rim of a motorcycle)
____A. No reaction
____B. Grabs ears
____C. Screams, yells, runs or other overt reaction
2. Do large crowds bother your son/daughter
____A. Yes
____B. No
3. Does being hit by dirt or feeling dirty significantly affect your son/daughter’s personality?
____A. Yes
____B. No
4. Do bright lights agitate or frustrate your son/daughter?
____A. Yes
____B. No
5. Is your son/daughter extremely scared of the dark even when you are with him?
____A. Yes
____ B. No

6. Has your son/daughter recently run away from you without apparent reason?

____A. Yes
____B. No

Required Answers: Question 1. Acceptable Answer 1 A and 1 B: Questions 2-6 No

Autistic Person’s Name/Age:________________________________________ ____
Parent’s Name:______________________________________________________
Signature of at least one of the custodial Parents:________________________________
Address:________________________ City/State____________________________
Email the above to:

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