Redbridge Autism Alert Card
ID No:
Card Application Form
Card Holder Details
First Name:
Date of birth:
Address:
Surname:
Postcode:
Are you usually accompanied when you are outside?
Yes/No
Do you have any disabilities in addition to your
Autism that makes communication more difficult
e.g no use of language, or deafness? Please give details.
Contact details of First Contact Person (contactable at all times)
First name:
Relationship with
Card Holder:
Contact Address:
Surname:
Postcode:
Phone number:
Mobile:
Contact details of Second Contact Person
First name:
Relationship with
Card Holder:
Contact Address:
Surname:
Postcode:
Phone number:
Mobile:
If you don’t have a formal diagnosis but you feel the card will be useful for you, please contact Redbridge
Disability Consortium on 020 8925 2435 or [email protected] . Your details will be
held on a secure database. We would like to contact from time to time about events or issues that may
be of interest to you, please confirm if you are happy for us to do so - Yes / No
Please return your completed form to: Autism Alert Card, RDC, 98-100 Ilford Lane, Ilford, Essex, IG1 2LD
Working in Partnership to develop the Redbridge Autism Alert Card:
Redbridge Disability
Consortium
Registered Charity No: 1065770
Company Limited by Guarantee No: 3115971
Redbridge Autism Alert Card
MONITORING INFORMATION
ETHNICITY PLEASE TICK √
WHITE
British/ English
Irish
Any Other White Background
Caribbean
African
Any Other Black Background
MIXED
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed Background
ASIAN
Indian OR ASIAN BRITISH
Pakistani
Bangladeshi
Any Other Asian Background
OTHER
Chinese ETHNIC GROUPS
Any Other Ethnic Groups
Prefer not to say
AGE
Please circle one of the options below:
Age
Groups
1 – 17
18 – 24
25 – 44
45 – 54
55 – 64
65 +
Prefer not to say
Working in Partnership to develop the Redbridge Autism Alert Card:
Registered Charity No: 1065770
Company Limited by Guarantee No: 3115971
Redbridge Autism Alert Card
RELIGION
I would describe my religion as the following (please indicate
one):
None
Christian
Buddhist
Hindu
Sikh
Jewish
Other (please specify):
Muslim
Prefer not
to say
GENDER
I would describe myself as the following (please indicate one):
Female
Male
Transgender
SEXUAL ORIENTATION
I would describe myself as the following (please indicate one):
Heterosexual
Homosexual
Lesbian
Bisexual
Other
Prefer not to say
Working in Partnership to develop the Redbridge Autism Alert Card:
Registered Charity No: 1065770
Company Limited by Guarantee No: 3115971