Voluntary Autism Registry

What is the Voluntary Autism Registry?

It’s completely voluntary.
It’s only accessed by the Royal Newfoundland Constabulary.
You can request to be removed if you change your mind.
It can influence the interactions between you and / or your child, should police response be needed.
ASNL cannot access the registry.
Information will be shared within the Department of Justice and Public Safety

If you have any questions or concerns please contact ASNL COO, Tess Hartmann 709-722-2803 ext. 232 thartmann@autism.nf.net

Voluntary Autism Registry Form

“Through this form, the Autism Society, Newfoundland Labrador (ASNL), and the Royal Newfoundland Constabulary (RNC), will collect information that can identify you and/or a family member or other person. Such identifying information may include your name, date of birth, e-mail, physical address, mailing address and other similar information (“personal data”) that you have voluntarily provided.

The Royal Newfoundland Constabulary is authorized to collect the information that you voluntarily supply on this Autism Registry Form per Section 32 of the Access to Information and Protection of Privacy Act S.N.L.2002 c A-1.1 (ATIPPA). The Royal Newfoundland Constabulary will use this personal data for law enforcement purposes including responding to requests you may make and/or interactions with the person(s) named on this form. From time to time, we may refer to the personal data to better understand your needs and/or the needs of the person named on this form and to better understand how we can improve our services in relation to you and/or your family and the person named on this form.

It is your responsibility to ensure that the personal data collected is current and valid, and that the Autism Society, Newfoundland Labrador, is notified in writing of any changes.

The retention, as well as any other use or disclosure, of the personal data by the Royal Newfoundland Constabulary is regulated in accordance with the provisions of the ATIPPA.

The retention, as well as any other use or disclosure, of the personal data by the Autism Society, Newfoundland Labrador is governed by its internal “Privacy Policy” and in accordance with the regulations of the Personal Information Protection and Electronic Documents Act, S.C. 2000, c. 5 (PIPEDA) and the Regulations made thereunder.” The Autism Society, Newfoundland Labrador, also voluntarily complies with provisions of the Personal Health Information Act, SNL 2008, c. P-7.01 (PHIA).
By checking this box I indicate my agreement with the Preamble on Personal Health Information.*
- I Agree

Please Note: Only Residents of the St. John’s Metro Region patrolled by the Royal Newfoundland Constabulary are eligible to register.
Registration*
- New Registration
- Renew Registration
Person with Autism - Information
Name
First Last
Nickname or name most likely to respond to*
Age*
Date of Birth*
YYYY dash MM dash DD
Gender*
- Male
- Female
Height (ft)*
Weight (lbs)*
Hair Colour*
Facial Hair*
Complexion*
Eye Colour*
Scars or Birthmarks (please indicate location on body)*
Glasses*
Diagnosis*
Type of Medical Alert ID if worn*
Location of ID*
Medications*
Does s/he have any other medical conditions or take medication? If so, please describe:*
Are there any life threatening medical concerns?*
Preferable method of Communication*
- Verbal
- Non-Verbal
- Sign Language
- Written Text/Pictures
If non-verbal, preferable method of communication:
Address Information
Address
Street Address Address Line 2 City Province Postal Code
Phone*
Cell Phone
Email*
School Address Information
(if applicable)
School Name
School Address
Street Address Address Line 2 City Province Postal Code
School Phone
Teacher(s) Name(s)
Parent/Emergency Contact #1 Information
Name*
First Last
Relationship*
Address
Street Address Address Line 2 City Province Postal Code
Phone
Email
Section Break
Parent/Emergency Contact #2 Information
First Last
Relationship
Address
Street Address Address Line 2 City Province Postal Code
Phone
Please list any other emergency contacts below.
Other Information
Is s/he able to communicate with speech?*
Does s/he understand receptive language (what is said to him/her)? If not, describe his/her method of communication*
Would s/he be able to communicate name, address and telephone number in a high stress situation?*
Does s/he engage in any behaviors that might seem disrespectful or threatening (yelling, giggling, standing too close to people)? If so, please describe:*
What might trigger sensory overload and what behaviors/actions are exhibited as a result of the sensory overload?*
Does s/he have any specific fascinations (water, tree climbing, trains)? If so, please describe:*
Is s/he a runner or wander? Is there a favorite place to run or wander?*
Does s/he have an accurate sense of danger?*
Best method of approach (Include approach and de-escalation techniques):*
Please describe anything else that would be helpful to emergency personnel who may have to respond to your household and interact with him or her.*
Is there any other info that many help responding emergency personnel?”
Release
By checking this box and typing my name, I give permission to the Royal Newfoundland Constabulary and the Autism Society, Newfoundland Labrador, to retain and distribute the personal data contained on this form for law enforcement purposes, including use by first responding personnel for the purpose of identification and assistance to the person(s) named on this form.*
- I Agree
Name (parent/legal guardian/self)*
First Last
Date*
YYYY dash MM dash DD

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Voluntary Autism Registry Form

Person with Autism - Information

Address Information

School Address Information

Parent/Emergency Contact #1 Information

Section Break

Other Information

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