Project Safeguard

Project Safeguard is a project in partnership with the community and Salt Lake Valley Law Enforcement. This online program promotes communication and gives police quick access to important information about a person who displays a tendency to wander; such as Autism, Dementia or other disability with similar tendencies. This program provides information that is critical for law enforcement prior to an officer's arrival at a scene and/or prior to contacting an individual with disabilities. Rapid access to information such as their name, birthday, physical description, emergency contact information, known triggers and behaviors etc. will help Officers during their initial response. Please share all information you feel comfortable providing. This form should be filled out yearly to insure accurate information is available for first responders. You will receive a notification at the end of each year to refresh your information.

PERSON COMPLETING THIS FORM

Phone
Submission Type*

Mark if this is a New Entry or Renewal

PERSON WITH DISABILITY INFORMATION

Gender*

Scars, Birthmarks, Tattoos, other Identifying Features

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

Drag and drop files here or

DISABILITY INFORMATION

Mark NA if not applicable

Communication Method*

Mark NA if not applicable

Will They Respond To Their Name Being Called*

RESIDENCE INFORMATION

Select or enter value
Caret IconCaret symbol
Phone
Weapons in the Home?*
Weapons Properly Secured?*

AUTISTIC CHARACTERISTICS

Complete this section if person with disability is Autistic.

Sensory Issues
Touch
Sounds
Bright Lights

Mark NA if not applicable

DISABILITY CHARACTARISTICS

Process Delays*

Mark NA if not applicable

Mark NA if not applicable

Mark NA if not applicable

Mark NA if not applicable

Mark NA if not applicable

Mark NA if not applicable

Alcohol/ Drug Issues*
Does the Family Have a Crisis Plan

WANDERING

Prior Wandering Incident*

Mark NA if not applicable

Mark NA if not applicable

Mark NA if not applicable

Mark NA if not applicable

Mark NA if not applicable

SCHOOL INFORMATION

Mark NA if not applicable

Mark NA if not applicable

Mark NA if not applicable

Mark NA if not applicable

Mark NA if not applicable

WORK INFORMATION

Mark NA if not applicable

Mark NA if not applicable

Mark NA if not applicable

Mark NA if not applicable

PRIMARY GUARDIAN/CARETAKER INFORMATION

Phone

Mark NA if not applicable

Phone

Mark NA if not applicable

Mark NA if not applicable

SECONDARY GUARDIAN/CARETAKER INFORMATION

Phone

Mark NA if not applicable

Phone

Mark NA if not applicable

Mark NA if not applicable

PRIMARY EMERGENCY CONTACT INFORMATION

Other than previously identified Guardians

Phone

Mark NA if not applicable

Phone

VEHICLE INFORMATION

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.

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.

Problems with Form Submission

Please contact Danie Bills - dbills@updsl.org if your are having trouble submitting this form.

Privacy Notice|Report Abuse