SPECIAL NEEDS NOTIFICATION FORM
In order to provide considerate and effective response to our residents, any person may voluntarily provide critical information on a family member, of any age, with special needs such as autism, Down's Syndrome, Alzheimer's disease, dementia, or any other cognitive impairment or condition that you feel we should know. This strictly confidential information will only be shared with responding officers to ensure a safe resolution to whatever we can assist you with.
Date of Registration
*
-
Month
-
Day
Year
Special Needs Diagnosis
*
Name of Subject
*
Nickname
DOB
*
-
Month
-
Day
Year
Sex
Please Select
Male
Female
Other
Race
Height
Weight
Eye Color
*
Please Select
Brown
Blue
Green
Hazel
Grey
Amber
Black
Red
Other
Hair Color
*
Please Select
Black
Brown
Blonde
Auburn
Red
Grey
White
Bald
Other
Scars or Identifying Marks
Medical Conditions
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Method of Communication if non-verbal
Sign Language, Written Word, etc.
Identification Worn
Jewelry/Medical Alert, Clothing Tags, Tracking Monitor
Triggers or Aversions
Conversation Starters
Inclination for Wandering Behaviors or Characteristics That May Attract Attention
Favorite Attractions or Locations Where Person May Be Found If Missing
Likes and Dislikes (De-escalation Techniques)
Caregiver Info
Caregiver/Next of Kin Name
Phone
Please enter a valid phone number.
Caregiver Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
example@example.com
Misc. Info
Photos
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