_

PERSON COMPLETING THIS FORM

Name - Person Completing Form*

Phone*

Phone

Email*

Relationship to Person with Disability*

Submission Type*

Mark if this is a New Entry or Renewal

New Entry

Renewal

PERSON WITH DISABILITY INFORMATION

First Name*

Last Name*

Race*

Gender*

Female

Male

Date of Birth*

Height*

Weight*

Hair Color*

Eye Color*

Identifying Features*

Scars, Birthmarks, Tattoos, other Identifying Features

File Attachments*

Upload a current photograph that only has the person you are submitting this form for in the picture.

Drag and drop files here or

DISABILITY INFORMATION

Primary Diagnosis*

Co-Existing Diagnosis*

Mark NA if not applicable

Communication Method*

Verbal

Non-Verbal

Describe if Non Verbal*

Mark NA if not applicable

Will They Respond To Their Name Being Called*

Yes

AUTISTIC CHARACTERISTICS

Complete this section if person with disability is Autistic.

Sensory Issues

Seekers

Sensory Avoidance

Touch

Seekers

Sensory Avoidance

Sounds

Seekers

Sensory Avoidance

Bright Lights

Seekers

Sensory Avoidance

Stimming Behavior

Mark NA if not applicable

DISABILITY CHARACTERISTICS

Process Delays*

Yes

Fears*

Mark NA if not applicable

Dislikes/ Triggers*

Mark NA if not applicable

Favorite Objects /Topics*

Pre-Meltdown Signs*

Mark NA if not applicable

Meltdown Behavior*

Mark NA if not applicable

Calming Strategies That Work*

Mark NA if not applicable

Prior Contact With Police*

Has this person had prior contact with the police? Please share as much information as possible about those interactions. What was the resolution? Are they fearful of police? Do they like police officers? etc. Mark NA if not applicable

Alcohol/ Drug Issues*

Yes

Does the Family Have a Crisis Plan*

Yes

WANDERING

Prior Wandering Incident*

Yes

If Prone To Wandering, Where Have They Been Found?*

Mark NA if not applicable

Closest Water To Residence*

Mark NA if not applicable

List All Lakes, Ponds, Streams, Pools, Etc*

Mark NA if not applicable

Favorite Hiding Places At Home*

Mark NA if not applicable

Favorite Hiding Places in Neighborhood/ Community*

Mark NA if not applicable

SCHOOL INFORMATION

School Name*

Mark NA if not applicable

Grade*

Mark NA if not applicable

School Address*

Mark NA if not applicable

School Contact Name

Mark NA if not applicable

School Contact Phone

Mark NA if not applicable

Bus Use*

Select or enter value

Facilities & Programs

Is the person enrolled in any programs with or do they frequent any facilities such as the Development Workshop, Journeys, etc.?*

Yes

If yes, please list the programs/facilities.*

Mark NA if not applicable.

If yes, please list the program/facility address(es).*

Mark NA if not applicable.

If yes, please list the program/facility contact person(s)*

Mark NA if not applicable.

If yes, please list the program/facility contact phone number(s).*

Mark NA if not applicable.

Is there any other relevant information you would like to include regarding their programs/service facilities?

RESIDENCE INFORMATION

Home Address*

City*

State*

Select or enter value

Phone*

Phone

Weapons in the Home?*

Yes

Weapons Properly Secured?*

Yes

Not Applicable

PRIMARY GUARDIAN/CARETAKER INFORMATION

Name*

Relationship*

Primary Phone*

Phone

Secondary Phone

Mark NA if not applicable

Phone

Place of Work*

Mark NA if not applicable

Work Address*

Mark NA if not applicable

SECONDARY GUARDIAN/CARETAKER INFORMATION

Name

Relationship

Primary Phone

Phone

Secondary Phone

Mark NA if not applicable

Phone

Place of Work

Mark NA if not applicable

Work Address

Mark NA if not applicable

PRIMARY EMERGENCY CONTACT INFORMATION

Other than previously identified Guardians

Name*

Relationship*

Primary Phone*

Phone

Secondary Phone

Mark NA if not applicable

Phone

Address*

VEHICLE INFORMATION

Vehicle 1 Make

Vehicle 1 Model

Vehicle 1 Year

Vehicle 2 Make

Vehicle 2 Model

Vehicle 2 Year

Add any additional information

RELEASE OF INFORMATION

I, hereby give my permission for any first responder agency (including but not limited to police, fire/rescue/EMS/911 dispatch center, search and rescue personnel) to retain and distribute the information contained in this registration form to other first responder personnel for the sole purpose of identification and protection of the person identified above in an emergency or crisis situation. By clicking the Release of Information box and typing your full name in the box below, you are agreeing to the release terms posted above.

RELEASE OF INFORMATION*

Your Full Name - Electronic Signature

Today's Date*

Send me a copy of my responses

Privacy Notice|Report Abuse