Child with Special Needs Information Form

Duchesne County Sheriff's Office

Sheriff Travis L Tucker
Message to Parents and Guardians from the Duchesne County Sheriff's Office

Dear Parents and Guardians,

The Duchesne County Sheriff's Office seeks your assistance in fostering a safer and more supportive environment for children in our community with special needs. Your insights and collaboration are invaluable to us.

We recognize the significance of equipping our law enforcement officers with the knowledge to best serve every child, especially those with limited language and communication skills. Your input holds the potential to make a significant impact in situations where officer assistance may be required.

By completing the enclosed form and providing a photograph, you enable us to respond more effectively. This allows our officers to offer assistance tailored to your child's needs, potentially reducing any stress and helping them feel safe.

Your understanding of what brings comfort and security to your child is invaluable to us. If you have specific insights on how our officers can provide better assistance in situations involving your child, please share them in this form below. Your input ensures that if a situation arises where our officers interact with your child, we are prepared to make that interaction as supportive and stress-free as possible.

Thank you for your participation in creating an empathetic and understanding community that supports the well-being of every child.

Sincerely,

Travis Tucker

Sheriff

Duchesne County Sheriff's Office

Contact Information
Child's Name*

First NameMiddle NameLast Name
Birthdate

MonthDayYear
Todays Date

MonthDayYear
Date
Age
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Attending
Parent/Guardian*

First NameMiddle NameLast Name
Phone Number*
Please enter a valid phone number.
Parent/Guardian

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.
Alternative Contact

First NameMiddle NameLast Name
Relationship
Please Specify
Phone Number
Please enter a valid phone number.

Tell us about your child*
Things that are helpful to our deputies to know are: What will help them calm down? What emotionally regulates your child to feel safe? What we as officers can do to help your child feel safe?
Image Upload
We encourage you to send any ideas or suggestions you may have to the following email address:

sheriff@duchesne.utah.gov

However, please note that due to privacy concerns, this form is intended exclusively for information about your child.
Should be Empty:

Duchesne County Sheriff's Office

Contact Information