Information

Read the Frequently Asked Questions.

Person with Autism - Information

Pour le service en francais composer le numero 705-476-2293 ext 1290 (Autism Ontario North Bay and Area)

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:		Build:
Hair Colour:		Hair Style:
Facial hair:		Facial hair colour:
Eye Colour:		Lens Type:
Marks/Scars/Tattoos:		Body location:
Description:
Photo (jpeg only)

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: (Help With This Item)
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 North Bay Police Service (NBPS) 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 NBPS 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 may be accessed by other Police Agencies who share a similar records management system or may be shared with other policing agencies at the request of a parent or guardian. It is acknowledged that it is your responsibility to ensure that the information so collected is current and valid, and that the NBPS 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. For additional information contact Autism North Bay and area or 705-476-2299 ext. 1290.


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