Down Syndrome Association of Jacksonville
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The StarLight
Project
Application

Apply to The StarLight Project

Thank you so much for your interest in The StarLight Project. Please complete the application below and submit. You may also print this form and mail it in to the address indicated on page 1. Contact us at thestarlightproject@gmail.com or (561) 670-1102 with any questions.

Fields In Bold Are Required

Child's Name:
First: Last:
Parent/Guardian Name:
First: Last:
Home Address:
Address:
City: State:
Zip:
Phone: Email:
Number of children in household:
Does your child have their own room: Yes No
If not, who does your child share a room with and what age are they:
Do you rent or own your home: Rent Own
If you rent, is your child's room able to be made over: Yes No
Parent/Guardian's Occupation:
Child's Date of Birth: Month: Day: Year (yyyy):
Child's Primary Diagnosis (ex. Autism, Cerebral Palsy, Down Syndrome):
Child's School:
School Contact #: School Contact Person:
Does your child have a primary therapist: Yes No
If yes, please include name and contact information of therapist:
Child's Special Interests (ex. cars, princesses, trains, specific colors, movies, music) Please list more than one interest as it relates to their dream bedroom:
Please provide examples of your child's favorite learning tools (bright colors, music, quiet personal space, lights and sounds, art/painting, etc):
Does your child have any specific dislikes:
Please explain why your child would be a good candidate for The StarLight Project:
Security Code:

**Please have your child's therapist or teacher provide us with a letter of recommendation to be completed online at: dsaj.org