Applicants Details

The personal information collected from you on this form is required by Autism New Zealand for the purposes of providing our services. It may also be used for statistical purposes in a way that will not identify the individual. The information collected will be held securely in our Dynamics 365 system and Autism New Zealand will respect the confidentiality of the information collected.

Providing some information is optional however if you choose not to enter your name or contact details, we may be unable to provide our services.

You have the right to ask for a copy of any personal information we hold about you, and to ask for it to be corrected if you think it is wrong. If you’d like to ask for a copy of your information, or to have it corrected, please contact us at lee.patrick@autismnz.org.nz, or 04 803 3501, or 20 Sydney St, Petone, 5012.

Under the privacy Act we are obliged to make sure all information you provide is not incorrectly assigned to someone else with the same name. Date of birth provides an initial measure of security so that this does not occur.

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* 1. First Name:

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* 2. Surname:

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* 3. Address:

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* 4. Email:

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* 5. Phone Number:

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* 6. Date of Birth:

Date

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* 7. Ethnicity (collected for funding purposes)

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* 8. Second Ethnicity:

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* 9. Gender

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* 10. Relationship to Autism

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* 11. Local Branch

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* 12. Email updates

Family Details - Immediate family, or extended family living with autism

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* 13. 1. Full Name:

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* 14. Date of Birth:

Date

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* 15. Relationship to you

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* 16. Relationship to Autism

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* 17. Ethnicity (collected for funding purposes)

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* 18. 2. Full Name:

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* 19. Date of Birth:

Date

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* 20. Relationship to you

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* 21. Relationship to Autism

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* 22. Ethnicity (collected for funding purposes)

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