To apply by post, please complete the following information and post to the address below. About You Name Autism Alert Card Address Email Address Bournemouth, Dorset and Poole Telephone Number Ethnicity Date of Birth Emergency Contact Details Name Relationship to Cardholder Telephone Number What is your diagnosis? I certify that the information I have provided on this form is correct to the best of my knowledge. Under the Data Protection Act 1998 consent must be obtained for manual/computerised processing of personal data for administration purposes. I agree for my personal information provided to Autism Wessex through this application to be stored securely and used anonymously for statistical purposes only. Get in touch Please return this form to: Autism Wessex Information & Advice Service South Grove Cottage, Trinity St Dorchester, DT1 1TU T 01305 213135 E [email protected] Wwww.autismwessex.org.uk Our services Autism Wessex (Information, Advice and Support Services) For further information on our services please visit www.autismwessex.org.uk Registered Charity No. 1000792 www.autismwessex.org.uk Remember! Carry your alert card with you at all times to help you get the right help when you need it. Funded by Dorset Police Information on the card includes: • Simple, practical advice • Cardholder’s name • Names and telephone numbers for two emergency contacts – these may be family members, Autism Alert Card carers or friends of the cardholder, who have agreed to be a contact on the card. Autism alert cards will be issued free of charge to people aged over 10 years on the autism spectrum, which includes Asperger syndrome. The Bournemouth, Dorset and Poole autism alert card scheme is managed and provided by Autism Wessex and funded by Dorset Police. The scheme is endorsed by the Pan-Dorset Autism Spectrum Condition Partnership Board, which is responsible for the Pan-Dorset Autism Strategy. The board is made up of representation from: The credit card-sized autism alert card should be carried at all times and be shown if you find yourself in a situation where you need help or need to give an explanation. It will also assist the police and other emergency services to identify that they are dealing with someone on the autism spectrum, which includes Asperger syndrome. My condition means I may: • People with autism, including Asperger syndrome • Carers AT TENTION • Dorset Police • Autism Wessex I have a condition on the autism spectrum, which includes Asperger syndrome • NHS Dorset Clinical Commissioning Group • R epresentatives from Adult Social Care for Bournemouth Borough Council, Bournemouth, Dorset and Poole Autism Alert Card Dorset County Council and the Borough of Poole • Havecommunicationdifficulties • Behaveinamannerthatcould appearalarming • Bevulnerableandneedsupport • Beanxious Mynameis 1stcontact 2ndcontact Funded by Dorset Police CardNo: Tel Tel 01305 213135 | [email protected] • Dorset Healthcare University Foundation Trust • Dorset Adult Asperger Support (DAAS) • Community Adult Asperger Service (CAAS) • Job Centre Plus How to apply • Representation from Children’s Services The scheme will provide autism awareness training to Bournemouth, Dorset and Poole police officers and other staff in the criminal justice system. Show this alert card if you need: • Support from one of your contacts • Help or consideration from police officers or other emergency services • To give people basic information about your condition Online: Email: Phone: Post: Complete an online application at www.autismwessex.org.uk Request an application form from [email protected] 01305 213135 Complete the form overleaf Your first autism alert card is free, replacements will cost £1. Full details of the Bournemouth, Dorset and Poole autism alert card scheme and how to apply can be found at www.autismwessex.org.uk
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