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AutismWes
2 Alma Street, Fremantle, WA, 6160

Contact Information & Youth Permission

Welcome to Autism West! To enable Autism West to meet ’duty of care’ obligations, and contact you if required, this form must be submitted prior to any participant trialling or attending our social groups.

The following information is used to communicate with parents/guardians regarding program information.

All information we receive, is managed within the Privacy Act 1988 (Cth).

If circumstances change, it is the responsibility of the signatory to advise Autism West of full details.

As an accredited NDIS service provider, Autism West adheres to child safe policies, and all staff are screened before being appointed. All staff engaging with the participants have a current Police Clearance, WA Working with Children’s Check and are suitably qualified for the role.



Number of parents and guardians covered by this form: 1 2

1. Parent / Guardian Information

Prefix: Surname:  ★ First Name:  ★
Address:  ★ Suburb:  ★ Postal Code:
Mobile:  ★ Home Phone: Work Phone:
Email 1:  ★ Email 2:    Relationship to Child:  ★

2. Parent / Guardian Information

Prefix: Surname:  ★ First Name:  ★
Address:  ★ Use same address as Parent 1 Suburb:  ★ Postal Code:
Mobile:  ★ Home Phone: Work Phone:
Email 1:  ★ Email 2:    Relationship to Child:  ★

Emergency Contact Details
In the event that parents/guardians cannot be contacted, AutismWest must have the information of someone else outside the family home (if possible) as an Emergency Contact. This section must be completed.
I have obtained the following person's permission to be the Emergency Contact for my children.
Surname:  ★ First Name:  ★
Address:  ★ Suburb:  ★ Postal Code:
Mobile:  ★ Email:    Relationship to Child:  ★


Number of children covered by this form: 1 2 3 4 5

1. Child Information

Surname:  ★ First Name:  ★ Also Known As:
Gender:  ★ Date of Birth:  ★ Nationality:
Street Address:  ★ Use same address as Parent 1 Use same address as Parent 2 Suburb:  ★ Postal Code:
Home Telephone: Mobile:  ★
Email 1:  ★ Email 2:
School Year:  ★
School Attending: Lives With:  ★
Group Name: Location:

Medical Information, Disabilities, Allergies and Dietary Requirements
If your child suffers from a condition, disability, or allergy that may need special attention while in AutismWest's care please provide information and care instructions.
If medication is to be administered then it must be supplied by the parents/guardians with clear instructions.

Does the child use an:   Inhaler/Puffer?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Does the child use an:   EpiPen/Auto-Injector?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Does the child have an ASCIA Action Plan for Allergic Reactions (Anaphylaxis)?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Does your child have a Behavioural Management Plan?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Are there any special requirements, access or guardian issues you need to inform of us?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)


Please note any special conditions, dietary requirements or care instructions:

Other Information
Please provide other infirmation you consider important about your child(ren) which will help AutismWestprovide better care for them while they attend AutismWest programs:

Media Information
Will you give permission to use any photos/digital media taken by us (which may identify your child/ward) to be used for publicity within AutismWest eg. noticeboards, photo presentations? Yes   No  

Will you give permission to use any photos/digital media taken by us (which may identify your child/ward) to be used for publicity in a broader capacity such as flyers and the AutismWest's website? Yes   No  


NDIS
NDIS Plan ID: NDIS Plan Name:
Funding Type: NDIS Type:

2. Child Information

Surname:  ★ First Name:  ★ Also Known As:
Gender:  ★ Date of Birth:  ★ Nationality:
Street Address:  ★ Use same address as Parent 1 Use same address as Parent 2 Suburb:  ★ Postal Code:
Home Telephone: Mobile:  ★
Email 1:  ★ Email 2:
School Year:  ★
School Attending: Lives With:  ★
Group Name: Location:

Medical Information, Disabilities, Allergies and Dietary Requirements
If your child suffers from a condition, disability, or allergy that may need special attention while in AutismWest's care please provide information and care instructions.
If medication is to be administered then it must be supplied by the parents/guardians with clear instructions.

Does the child use an:   Inhaler/Puffer?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Does the child use an:   EpiPen/Auto-Injector?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Does the child have an ASCIA Action Plan for Allergic Reactions (Anaphylaxis)?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Does your child have a Behavioural Management Plan?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Are there any special requirements, access or guardian issues you need to inform of us?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Please note any special conditions, dietary requirements or care instructions:

Other Information
Please provide other infirmation you consider important about your child(ren) which will help AutismWestprovide better care for them while they attend AutismWestprograms:

Media Information
Will you give permission to use any photos/digital media taken by us (which may identify your child/ward) to be used for publicity within AutismWest eg. noticeboards, photo presentations? Yes  No  

Will you give permission to use any photos/digital media taken by us (which may identify your child/ward) to be used for publicity in a broader capacity such as flyers and the AutismWest's website? Yes  No  


NDIS
NDIS Plan ID: NDIS Plan Name:
Funding Type: NDIS Type:

3. Child Information

Surname:  ★ First Name:  ★ Also Known As:
Gender:  ★ Date of Birth:  ★ Nationality:
Street Address:  ★ Use same address as Parent 1 Use same address as Parent 2 Suburb:  ★ Postal Code:
Home Telephone: Mobile:  ★
Email 1:  ★ Email 2:
School Year:  ★
School Attending: Lives With:  ★
Group Name: Location:

Medical Information, Disabilities, Allergies and Dietary Requirements
If your child suffers from a condition, disability, or allergy that may need special attention while in AutismWest's care please provide information and care instructions.
If medication is to be administered then it must be supplied by the parents/guardians with clear instructions.

Does the child use an:   Inhaler/Puffer?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Does the child use an:   EpiPen/Auto-Injector?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Does the child have an ASCIA Action Plan for Allergic Reactions (Anaphylaxis)?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Does your child have a Behavioural Management Plan?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Are there any special requirements, access or guardian issues you need to inform of us?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Please note any special conditions, dietary requirements or care instructions:

Other Information
Please provide other infirmation you consider important about your child(ren) which will help AutismWestprovide better care for them while they attend AutismWestprograms:

Media Information
Will you give permission to use any photos/digital media taken by us (which may identify your child/ward) to be used for publicity within AutismWest eg. noticeboards, photo presentations? Yes  No  

Will you give permission to use any photos/digital media taken by us (which may identify your child/ward) to be used for publicity in a broader capacity such as flyers and the AutismWest's website? Yes  No  


NDIS
NDIS Plan ID: NDIS Plan Name:
Funding Type: NDIS Type:

4. Child Information

Surname:  ★ First Name:  ★ Also Known As:
Gender:  ★ Date of Birth:  ★ Nationality:
Street Address:  ★ Use same address as Parent 1 Use same address as Parent 2 Suburb:  ★ Postal Code:
Home Telephone: Mobile:  ★
Email 1:  ★ Email 2:
School Year:  ★
School Attending: Lives With:  ★
Group Name: Location:

Medical Information, Disabilities, Allergies and Dietary Requirements
If your child suffers from a condition, disability, or allergy that may need special attention while in AutismWest's care please provide information and care instructions.
If medication is to be administered then it must be supplied by the parents/guardians with clear instructions.

Does the child use an:   Inhaler/Puffer?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Does the child use an:   EpiPen/Auto-Injector?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Does the child have an ASCIA Action Plan for Allergic Reactions (Anaphylaxis)?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Does your child have a Behavioural Management Plan?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Are there any special requirements, access or guardian issues you need to inform of us?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Please note any special conditions, dietary requirements or care instructions:

Other Information
Please provide other infirmation you consider important about your child(ren) which will help AutismWestprovide better care for them while they attend AutismWestprograms:

Media Information
Will you give permission to use any photos/digital media taken by us (which may identify your child/ward) to be used for publicity within AutismWest eg. noticeboards, photo presentations? Yes  No  

Will you give permission to use any photos/digital media taken by us (which may identify your child/ward) to be used for publicity in a broader capacity such as flyers and the AutismWest's website? Yes  No  


NDIS
NDIS Plan ID: NDIS Plan Name:
Funding Type: NDIS Type:

5. Child Information

Surname:  ★ First Name:  ★ Also Known As:
Gender:  ★ Date of Birth:  ★ Nationality:
Street Address:  ★ Use same address as Parent 1 Use same address as Parent 2 Suburb:  ★ Postal Code:
Home Telephone: Mobile:  ★
Email 1:  ★ Email 2:
School Year:  ★
School Attending: Lives With:  ★
Group Name: Location:

Medical Information, Disabilities, Allergies and Dietary Requirements
If your child suffers from a condition, disability, or allergy that may need special attention while in AutismWest's care please provide information and care instructions.
If medication is to be administered then it must be supplied by the parents/guardians with clear instructions.

Does the child use an:   Inhaler/Puffer?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Does the child use an:   EpiPen/Auto-Injector?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Does the child have an ASCIA Action Plan for Allergic Reactions (Anaphylaxis)?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Does your child have a Behavioural Management Plan?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Are there any special requirements, access or guardian issues you need to inform of us?   Yes  No  ★   (If yes, please attach supporting documentation at the bottom of this form.)

Please note any special conditions, dietary requirements or care instructions:

Other Information
Please provide other infirmation you consider important about your child(ren) which will help AutismWestprovide better care for them while they attend AutismWestprograms:

Media Information
Will you give permission to use any photos/digital media taken by us (which may identify your child/ward) to be used for publicity within AutismWest eg. noticeboards, photo presentations? Yes  No  

Will you give permission to use any photos/digital media taken by us (which may identify your child/ward) to be used for publicity in a broader capacity such as flyers and the AutismWest's website? Yes  No  


NDIS
NDIS Plan ID: NDIS Plan Name:
Funding Type: NDIS Type:

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Consent

Year covered by this form:    

I,  give full permission for   to participate in all activities at AutismWest.
I give full permission for my child/children to participate in all activities at Autism West.

• I consent to my child/children being taken out on excursions with Autism West, using both private and public transport as arranged when necessary.

• I have supplied full behavioural, health and dietary information and provided all necessary medical plans and details of emergency contacts.

• I acknowledge that in the event of an emergency, it is Autism West’s intention to make every effort to contact me or the people listed as emergency contacts. If contact cannot be made, I give permission to my child/children receiving ambulance, or any emergency medical care necessary, and I accept full responsibility for all expenses incurred.
  I have read, understood and agree with all the conditions outlined in this form.  ★

Signed:   Date:   23/2/20 Relationship to Child/Children:  


Thank you for taking the time
to complete this form.
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