About You

Name
required

Date of Birth

Address
required

Telephone Number

Email Address

Emergency Contact Details

Name
required

Telephone Number
required

Do you have autism or Asperger Syndrome?

Please state which
required

When were you diagnosed?
required

Who provided the diagnosis?
required

Please tick which best describes your ethnic origin.

Autism West Midlands is continually striving to establish how we can better meet the needs of the different ethnic communities within the West Midlands. We would therefore be grateful if you could complete the following in regard to the person applying for an Attention Card. Thank you for your help.

Bangladeshi
Indian
Pakistani
Asian (other)
African Caribbean
White (British)
White (Irish)
White (Other)
Other - Please State
Other

 

Is This A New Or Replacement Card?

New Card
Replacement Card

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 lawful manual / computerised processing of personal data for administration purposes. I agree for my personal information provided to autism.west midlands through this form to be kept on file, processed on a database and used anonymously for statistical purposes.