Autism/Development Disability Registration Form
Please fill this form out fully for the person you are registering.
Name
First Name
Last Name
Answers to what name/nickname
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
Race
Complexion
Hair Color
Sex
Please Select
Male
Female
Other
Eye Color
Please Select
Hazel
Blue
Green
Brown
Grey
Height
Weight
Facial Hair?
Take Photo
Scars or Identifying Marks
School/Employer
Method of Communication?
Any identification worn? If so, please describe
What are they attracted to outside of the home?
Favorite attractions and locations person may be found?
Best methods of approach?
Medical Concerns:
Diagnosis:
Is there anything we should AVOID when approaching?
Does this person drive?
Please Select
Yes
No
Type of Vehicle
Registration
Color of Vehicle
Emergency Contact
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Relationship
Date of Birth
Any additional information that may be helpful?
Submit
Should be Empty: