Special Needs/Mental Health Information Form

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Please correct the field(s) marked in red below:

* Denotes required fields
1
Person Completing Form
 *
2
Special Needs/Mental Illness Person Information
 *
3
Residence Information
 *
Residence Information
4
Parent or Guardian Information
(First)
 *
Parent or Guardian Information (First)
5
Parent or Guardian Information
(Second)
Parent or Guardian Information (Second)
6
Special Needs/Mental Illness Symptomalogy
 *
Special Needs/Mental Illness Symptomalogy
7
Characteristics
Characteristics
8

Emergency Contact Information
(first)

 *
Emergency Contact Information (first)
9

Emergency Contact Information
(second)

Emergency Contact Information (second)
10
Case Worker or Person Responsible for Care
 *
Case Worker or Person Responsible for Care
11
School Information
School Information
12
Vehicle Information
Vehicle Information
13
Additional Information
Additional Information

14

Release and Submit


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 typing your name in the box, you are agreeing to the release terms posted above.

 *
Release and Submit 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 typing your name in the box, you are agreeing to the release terms posted above.
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