Voluntary Autism Registry Form 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 RegistrationRenew RegistrationPerson with Autism - InformationName First Last Nickname or name most likely to respond to*Photo*Yes; I have a photo for the registry ID card (e.g. passport photo)No; I do not have a photo for the registry ID card (please contact ASNL to arrange a photo appointment).Photo UploadAccepted file types: jpg, gif, png.If Yes, affix Photo hereDate of Birth* Date Format: YYYY dash MM dash DD Gender*MaleFemaleHeight (ft)*Weight (lbs)*Hair Colour*Facial Hair*Complexion*Eye Colour*Scars or Birthmarks*Glasses*Diagnosis*Type of Medical Alert ID if worn*Location of ID*Medications*Preferable mode of Communication*VerbalNon-VerbalIf non-verbal, preferable method of communication:Address InformationAddress Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone*Cell PhoneEmail* School Address Information(if applicable)School Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code School PhoneTeacher(s) Name(s)Emergency Contact InformationName* First Last Relationship*Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code PhoneEmail Name First Last RelationshipAddress Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code PhoneOther InformationIs 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?*Are there any life threatening medical concerns?*Does s/he engage in any unusual behaviors that might seem disrespectful or threatening (yelling, giggling, standing too close to people)? If so, please describe:*Is s/he prone to sensory overload? Identify what may result from sensory overload and what might trigger a sensory overload?*Does s/he have any specific fascinations (water, tree climbing, trains)? If so, please describe:*Is there a favorite place s/he may go if wandering?*Does s/he have an accurate sense of danger?*Does s/he have any other medical conditions or take medication? If so, please describe:*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.*ID CardWould you like to receive a Voluntary Autism Registry Photo ID card?*YesNoReleaseBy 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* Date Format: YYYY dash MM dash DD
