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