2. Name of Child/Adult with Special Needs:
4. Nickname (if any):
5. Date of Birth:
7. Height:
8. Weight:
9. Eye Color:
10. Hair Color:
12. Medical Conditions:
13. Scars/Identifying Marks:
15. Address1
17. City
18. State
19. Zip
21. Contact Number(s):
23. Method of communication, if non-verbal (ex. Sign language, picture boards, written word, etc.):
25. Identification Worn (ex. Jewelry, Medic Alert®, clothing tags, ID card, tracking monitor, etc.):
27. Current Prescriptions (include dosage):
29. Sensory/Medical/Dietary issues and requirements, if any:
31. Inclination for wandering behaviors or characteristics that may attract attention:
33. Favorite attractions or locations where person may be found, if missing:
35. Likes/Dislikes (Include approach and de-escalation techniques):
37. Medical Care Providers:
    Name/Phone
38. Parent/Caregiver Information:
    Name/Phone
40. Emergency Contact Information:
41. PHOTO
    Please upload a photo that would help officers identify the person with special needs referenced in this form.
43. What 911 Needs to Know
    -Location of the emergency – try to be as specific as possible; when did this occur? – again, try to be as specific as possible; description: clothing, race, sex, hair & eye color, identifying features, direction of travel, vehicle make, model, and color; circumstances surrounding the emergency.
45. Advice from 911
    When an emergency does occur and you call 911, be sure to mention that the individual involved has special needs. Stress the importance of this information to the dispatcher so the dispatcher can pass the information along to responders.
47. Premises Alerts
    The information on this form and any other pertinent information can be programmed into our CAD (computer aided dispatch) system. We assign alerts to citizens, residences, businesses, schools etc. as needed. The ability to identify citizens with special needs, their places of employment, educational facilities, and residences are valuable resources in instances when or if an emergency response is needed.
49. What You Can Do
    It is very important to work with family members that have special needs and help them determine what classifies as an emergency. Dispatchers are trained and understand that they are not to discourage the caller because what may be an emergency to someone else is not considered an emergency by the dispatcher. Make sure all of your family members are familiar with emergency services. Schedule a tour at the police and fire department. Allow your family members to get acclimated and comfortable with the equipment and personnel. Recognizing and learning that the person behind the uniform or safety equipment is someone who is there to help you is very important.
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