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Change of Details Form

Please use this form to update details of an individual already registered with Autism Queensland. This is not a registration form.

N.B. The information you have provided is for Autism Queensland records ONLY. It is not shared with any other parties, for example the Department of Social Services, NDIS etc. You will need to contact these services separately to update details.

INDIVIDUAL DETAILS (To be completed by legal guardian/s or registered individual if over 18 years)

First Name (please provide LEGAL names only, not aliases):*

First Name (ONLY if name above has changed):

Middle Name/s:

Surname:*

Surname (ONLY if name above has changed):

Gender:*

MaleFemaleMxOther

Date of Birth:*

Please complete sections which are applicable (eg details for registered individual have changed). If the changes are to do with parent/caregiver details please proceed to next parts of the form.

Email:

Mobile or other phone number:

Street Name & Number:*

Suburb:*

State*:

Postcode:*

PART 2 - Parent/Legal Guardian/Caregiver 1 - To be completed by legal guardian/s authorized to act on behalf of registered individuals.

Have your details changed:*

Yes - complete this section

No - go to Part 3

Title:

First Name:

Surname:

Relationship to registered individual:

Mobile phone number:

Email:

Full Address (if different to above):

PART 2 - Parent/Legal Guardian/Caregiver 2 - To be completed by legal guardian/s authorized to act on behalf of registered individual.

Have your details changed?*

Yes - complete this section

No - go to Part 3

Title:

First Name:

Surname:

Relationship to registered individual:

Other phone number:

Email:

Full Address (if different to registered individual's):

PART 3 - Declaration (must be completed by individual if aged over 18 years or legal guardian/s authorized to act on behalf of registered individual.

Name of person completing form:*

Relationship to registered individual:*

Phone number (if different to above):

DECLARATION:
I have the legal authority to complete this form as the registered individual or as a person who is authorised to act on their behalf. All information provided is true and correct.

I accept and acknowledge the above declaration:*

Yes

Personal and sensitive information collected on this form will be retained and used for the purpose of providing you with Autism Queensland Limited’s services and providing information about these services. It may also be used for other purposes such as providing you with information about other services and events, to meet our requirements for government funding in providing services, to monitor and evaluate existing services and plan for future services or for research purposes. Without this information Autism Queensland may be unable to provide you with its service. The information collected on this form will only be used by Autism Queensland and will not be disclosed to any other person or organisation unless we have your consent or we are permitted by law. If you wish to access or seek correction of your personal information or make a complaint about our handling of your personal information please see Autism Queensland’s Privacy Policy or phone (07) 3273 0000.