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AutismWes
2 Alma Street, Fremantle, WA, 6160

Adult Contact Information

Welcome to Autism West! We require the following information to enable us to carry out our ’duty of care’ and contact you if required. This form must be submitted prior to any participant entering our social groups.

The following information is used to communicate with you or your 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.

Please note as a participant, if you wish to volunteer or engage with participants in our adolescent groups, you will require a current Police Clearance and Working with Children’s Check and an induction.



 Contact Details
Surname:  ★ First Name:  ★ Also Known As:
Gender:  ★ Date of Birth: Nationality:
Street Address:  ★ Suburb:  ★ Postal Code:
Home Telephone: Mobile:
Email 1:  ★ Email 2:
Group Name: Location:

Medical Information, Disabilities, Allergies and Dietary Requirements
If you suffer 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 someone with clear instructions.

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

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

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

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

Are there any special requirements 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 yourself which will help AutismWest provide better care for you while you attend AutismWest programs:




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

 Emergency Contact Details
In the event that there is an incident, 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 myself.
        Surname:  ★ First Name:  ★
Use same address as contact person  Address:  ★ Suburb:  ★ Postal Code:
Telephone:  ★ Email:    Relationship to You:  ★

 Emergency Contact Details
In the event that there is an incident, 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 myself.
        Surname: First Name:
Use same address as contact person  Address: Suburb: Postal Code:
Telephone: Email:    Relationship to You:

   Select a file:  
  
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 Consent

Year covered by this form:    ★
I give full permission to participate, or for my dependant to participate in all activities at Autism West.

• I consent to 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 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 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


Thank you for taking the time
to complete this form.
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