FLAGLER COUNTY SHERIFF'S OFFICE / Autism Awareness

Rick Staly, Sheriff
FLAGLER COUNTY SHERIFF'S OFFICE

“An honor to serve, a duty to protect.”
SIGN UP FOR AUTISM AWARENESS PROGRAM
Name

First NameLast Name
Nicknames
Add Current Photo

Cancelof
Date of Birth

MonthDayYear
Date
Race

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
Sex

FemaleMaleOther
Eye Color

BlueBrownGreenHazelAmberGrayOther
Hair Color

BlackBrownBlondeGrayRedBaldOther
Height (Ft. and In.)
Weight (Lbs.)
Primary Language Spoken
Diagnosis
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Home Phone
Alternate Phone
Parent or Caretaker
1. Name

First NameLast Name
Relationship
Work/Home
Cell
2. Name

First NameLast Name
Relationship
Work/Home
Cell
Emergency Contact

First NameLast Name
Relationship
Work / Home
Cell
Questionnaire
Is he/she verbal or non-verbal

VerbalNon-Verbal
If non-verbal, how does he/she communicate?
What type of behavior should be expected?

KickingHittingBitingSpittingSelf-HittingHand-FlappingSelf-TalkBody RockingOther
What is his/her favorite toy, objects, music, discussion topics, likes and dislikes?
What is the best way to approach him/her?
Does he/she have any sensitivities/triggers?

YesNo
Sensitivities/Triggers:

LightSirenLoud Radio NoiseOther
If he/she becomes confrontational, how can Deputies calm him/her down?
Any other pertinent information you would like to provide?
How many Autism Awareness stickers would you like for your home?

OneTwoThree
How many Autism Awareness stickers would you like for your vehicles?

OneTwoThree
My signature below constitute an affirmation that I am legally responsible for the person named above for whom I have provided this information
Electronic Signature

Clear
Printed Name
Date

MonthDayYear
Date
If unable to electronically sign, please print form, sign and return to: communityengagement@flaglersheriff.com or mail to P.O. Box 879, Bunnell, FL 32110

Any question regarding this program or this form, please email communityengagement@flaglersheriff.com or call 386.586.4845

Distribution: Original to Linked To: FCSO Form #INVS-215 (03/22)
Should be Empty:

Rick Staly, Sheriff

FLAGLER COUNTY SHERIFF'S OFFICE

SIGN UP FOR AUTISM AWARENESS PROGRAM

Parent or Caretaker

Questionnaire