* Denotes required fields

1

Person Completing Form

 *

Person Completing Form(Select an Answer) Dr. Mr. Mrs. Ms / Miss	First Name*
Last Name*	Email Address*
Phone*ext.	Relationship to special needs person

2

Special Needs/Mental Illness Person Information

 *

Special Needs/Mental Illness Person Information(Select an Answer) African-American American Indian / Alaskan Native Asian / Pacific Islander Hispanic White	Full Name*
Date of Birth* (mm/dd/yyyy)	Height*
Weight*	Gender*
Eye Color*	Hair Color*
Scars/Birthmarks/Tattoos

3

Residence Information

 *

Residence Information

Home Address*

City

Zip Code*

4

Parent or Guardian Information
(First)

 *

Parent or Guardian Information (First)

Name*

Primary Phone*ext.

Home

Work

Cell

Secondary Phoneext.

Home

Work

Cell

Place of Work

Work Address

Work Contact

Work Phoneext.

5

Parent or Guardian Information
(Second)

Parent or Guardian Information (Second)

Name

Primary Phoneext.

Home

Work

Cell

Secondary Phoneext.

Home

Work

Cell

Place of Work

Work Address

Work Contact

Work Phoneext.

6

Special Needs/Mental Illness Symptomalogy

 *

Special Needs/Mental Illness Symptomalogy

Primary Diagnosis*

Co-existing Diagnosis

Communication Method (verbal / non-verbal)

Desribe if non-verbal

7

Characteristics

Characteristics

Process Delays (yes / no)	Fears	Dislikes / Triggers
Favorite Objects / Topics	Pre-meltdown Signs	Meltdown Behavior
Calming Strategies	Physical aggression or prior contact with police	Weapons in the home (yes / no)?
Are weapons properly secured (yes / no)?	Alcohol / Drug Issues (yes / no)?	Does the family have a crisis plan (yes / no)?

8

Emergency Contact Information
(first)

 *

Emergency Contact Information (first)

Name*

Relationship*

Address*

City*

Primary Phone*ext.

Home

Work

Cell

Secondary Phoneext.

Home

Work

Cell

9

Emergency Contact Information
(second)

Emergency Contact Information (second)

Name

Relationship

Address

City

Primary Phoneext.

Home

Work

Cell

Secondary Phoneext.

Home

Work

Cell

10

Case Worker or Person Responsible for Care

 *

Case Worker or Person Responsible for Care

Name*	Phone*ext.
Agency*	Agency Phone*ext.

11

School Information

School Information

School Name	School Grade
School Address	School Contact
School Contact Phoneext.

12

Vehicle Information

Vehicle Information

Vehicle 1 Make	Vehicle 1 Model	Vehicle 1 Year
Vehicle 1 Color	Vehicle 1 License Plate Number	Vehicle 1 License Plate State
Vehicle 2 Make	Vehicle 2 Model	Vehicle 2 Year
Vehicle 2 Color	Vehicle 2 License Plate Number	Vehicle 2 License Plate State
Vehicle 3 Make	Vehicle 3 Model	Vehicle 3 Year
Vehicle 3 Color	Vehicle 3 License Plate Number	Vehicle 3 License Plate State

13

Additional Information

Additional Information

Attach a Recent Photograph Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

Add any additional information

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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.

Enter Your Full Name*

Enter Today's Date* (mm/dd/yyyy)

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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