Person with Autism - Information

New Form or Renewal :	New Form Renewal
Surname (Family name of child or adult with autism):
Given Name(s) (Child or adult with autism):

Gender:

Date of Birth (dd/mm/yyyy):

Nickname (Or any name that is most likely to respond to):

Address:		City:
Province:		Postal Code:
Home Phone:		Business Phone:
Address 2:
Employer/School:		Remarks:
Language:
Height (ft):		Weight: (lbs)
Complexion:	Dark Light/Fair Medium Other Ruddy Sallow Tan	Build:
Hair Colour:	Auburn Black Blonde Brown Dyed Grey Red Salt & Pepper White	Hair Style:	Brush Cut Curly Long Other Short Wavy
Facial hair:	Moustache Full Beard Partial Beard Goatee Side Burns Unshaven None Other	Facial hair colour:	Auburn Black Blonde Dyed Grey Red Salt & Pepper White
Eye Colour:	Black Blue Brown Green Grey Hazel	Lens Type:	Contacts Glasses None Other
Marks/Scars/Tattoos:		Body location:
Description:

Method of Communication:
Identification Worn:
Inclination for wandering or characteristics that may attract:
Favourite attractions and locations where person may be found:
Best method of approach (include approach and de-escalation techniques):
Life threatening medical concern:
Any other relevant information:
Information should include: favorite toys, names most likely to generate a positive response, reinforcers that are used, suggestions for de-escalation and /or cooperation (ie likes to hold pens)
Information should also include what NOT to do: ie physical and/or direct eye contact, lights, loud noises, etc.

Contact Information

Emergency Contact Information

Name:		Relationship:
Phone #1:		Phone #2:
Work:		Gender:
Address (if different than above):		Date of Birth (dd/mm/yyyy):

Secondary Contact

Name:		Relationship:
Phone #1:		Phone #2:
Work:		Gender:
Address (if different than above):		Date of Birth (dd/mm/yyyy):

Registered by

Through this form, the Ottawa Police Service (OPS) will collect information that can identify you or a family member. Such identifying information may include your name, date of birth, e-mail, address, mailing address and other similar information (“personal data”) when it is voluntarily submitted under Sec 29(1)(a) MFIPPA. The OPS will use your personal data to respond to request you make of us and/or interacting with the persons named. From time to time, we may refer to your personal data to better understand your needs and how we can improve our services in relation to you and / or your family. This information maybe be accessed by other Police Agencies through the Police Information Portal however consent must be provided for the use of such information. It is acknowledged that it is your responsibility to ensure that the information so collected is current and valid, and that the OPS is notified in writing of any changes. The retention, as well as any other use or disclosure, of the information will be dictated by the requirements under the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. M.56.

Name:		Relationship to child/adult with autism:
Address:		Date of Birth (dd/mm/yyyy):
Email: