Voluntary Autism Registry Form

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*

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).

Please include a recent and clear photo of the registrant.

Photo Upload

If Yes, affix Photo here. Please include clear, recent photo taken from the chest up.

Age*

Date of Birth*

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?”

ID Card

Would you like to receive a Voluntary Autism Registry Photo ID card?*

Yes
No

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*

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