Application

Autism Speaks Canada

The Look at Me Project

Autism Speaks Canada

Report Fields
1. First Name of the Recipient*
Character Limit: 100

Last Name of the Recipient*

Character Limit: 100

2. Recipient Information*
Does the individual with autism spectrum disorder (ASD) live at the address above?
If Yes, proceed to the next question.
If No, please provide the details below.
Choices
Yes
No

Recipient Information continued...

Number and Street
Character Limit: 100

Apt/Unit
Character Limit: 20

City
Character Limit: 50

Province
Character Limit: 30

Postal Code
Character Limit: 20

Does the recipient currently live in Canada?*

Choices
Yes
No

3. Relationship*
What is your relationship to the individual with ASD?
Printed On: 6 January 2015

The Look at Me Project

Application

Autism Speaks Canada

Choices
Parent
Self
Grandparent
Friend
Teacher
Service Provider
Medical Professional
Other

If Other, please specify.

Character Limit: 100

4. Source*
How did you find out about the Look at Me Project?
Choices
Autism Speaks Canada website
Samsung Canada website
Service Provider
Today's Parent
Facebook
Twitter
Other

Source Continued...
If Other, please specify.
Character Limit: 25

5. Other Portable Touch Device*

Does the individual with ASD have his/her own Samsung Tablet or other portable touch device?
Choices
Yes
No

6. Diagnosis*
What is the diagnosis of the individual who will use the Samsung Tablet?
Choices
Autism Spectrum Disorder (ASD)
Autism Disorder
Pervasive Development Disorder - Not Otherwise Specified (PDD-NOS)
High Functioning Autism
Aspergers Syndrome
Not Formally Diagnosed
No Connection to ASD
Other

Printed On: 6 January 2015

The Look at Me Project

Application

Autism Speaks Canada

If Other, please explain.

Character Limit: 100

7. Age*
How old is the individual with ASD? If you are applying for more than one child, you must fill
out an application for each.
Character Limit: 2

8. Communication*
What is the individual with ASD's ability to use verbal communication?
Choices
Nonverbal
3-4 word sentences
Conversational
Very Talkative

9. The Look at Me app*

The Look at Me Project is designed to create a collective community to enhance the
experiences of the families receiving the Samsung tablets and the Look at Me app. There will be
an online community linked to the website where parents and caregivers can share their
children's progress by sharing moments of connections (e.g. pictures or videos). As well, in
collaboration with parents and caregivers and consent, Samsung Electronics Canada and Autism
Speaks Canada will gather and document results of The Look at Me Project with participating
families after experiencing the Samsung Tab S device and The Look at Me App.

Are you willing to participate in the Look at Me online community.

Choices
Yes, I am willing to participate in the online community.
No, I am not willing to participate.

10. Need*
Demonstrate the individual with ASD need for a tablet. Please specify needs for
communication, social interaction and behavioural emotional support.
Character Limit: 1000

11. Benefit*
Please tell us how, when and where the individual with ASD will use the Samsung Tablet in their
daily living.
Character Limit: 1000

12. Impact*
Please tell us how the Samsung Tablet will impact the individual with ASD quality of life.
Printed On: 6 January 2015

The Look at Me Project

Application

Autism Speaks Canada

Character Limit: 1000

13. Disclosure*
This donation product will not be resold or used for other purposes other than what is stated in
the application.
Choices
Agree
Disagree

14. Testimonial*
If awarded a tablet, the individual with ASD and/or their parents or caregivers would share their
experience, participate in a follow up survey and submit a photo to Autism Speaks Canada. Any
personal information we collect for the purposes stated above will be used, stored and shared
with third parties such as Samsung Electronics Canada in accordance with Autism Speaks
Canada privacy policy available at http://www.autismspeaks.ca/privacy-policy.

If you have any questions, please contact us at lookatme@autismspeakscan.ca

You may opt out any time by contacting us at lookatme@autismspeakscan.ca

Do you consent to the collection, use, storage, sharing and disclosure by Autism Speaks Canada
of the personal information provided for the purposes specified above?
Choices
Agree
Disagree

15. Wi-Fi Access*

Do you have access to Wi-Fi in your home?
Choices
Yes
No

Wi-Fi Access continued...

If No, do you use Wi-Fi at work or within your community (public library, restaurants, etc.)?
Choices
Yes
No
Printed On: 6 January 2015

The Look at Me Project

Application

Printed On: 6 January 2015

Autism Speaks Canada

The Look at Me Project